
CopyrightN^, 



-BI^ 



COPYRIGHT DEPOSm 



PRACTICAL GYNECOLOGY 



MONTGOMERY 



PRACTICAL GYNECOLOGY 



A COMPREHENSIVE TEXT-BOOK 
FOR STUDENTS AND PHYSICIANS 



BY 

E. E. MONTGOMERY, M. D., LL. D. 

PROFESSOR OF GYNECOLOGY, JEFFERSON MEDICAL COLLEGE; GYNECOLOGIST TO THE JEFFERSON 

MEDICAL COLLEGE AND ST. JOSEPH'S HOSPITALS; CONSULTING GYNECOLOGIST TO THE 

PHILADELPHIA LYING-IN CHARITY, THE KENSINGTON HOSPITAL FOR WOMEN, AND 

CON'SULTING SURGEON TO THE JEWISH HOSPITAL. 



FOURTH EDITION 
REVISED AND REARRANGED 



WITH FIVE HUNDRED AND EIGHTY-NINE ILLUSTRATIONS, THE GREATER 
NUMBER OF WHICH HAVE BEEN DRAWN AND ENGRAVED SPECIALLY 
FOR THIS W^ORK, FOR THE MOST PART FROM ORIGINAL SOURCES 



PHILADELPHIA 

BLAKISTON'S SON & CO 

1012 WALNUT STREET 
1912 



^^.^^_ 






Copyright, 191 2, by P. Blakiston's Son & Co. 



I 



Printed "by 

The Maple Press 

York, Pa. 



C1.A305344 



') 



TO 
THE LATE 

DR. W. H. WARDER 

MY COXSCIEXTIOUS INSTRUCTOR AS QUIZ-MASTER AND HOSPITAL 
CHIEF, AND MY GENEROUS FRIEND, 

THIS BOOK IS RESPECTFULLY DEDICATED. 



PREFACE TO FOURTH EDITION. 



In the preparation of the fourth edition of this book I have so rear- 
ranged it as to secure what experience in teaching has demonstrated to be 
a more progressive order. It opens with special anatomy, which is 
followed in order by physiology; etiology; diagnosis; therapeutics, general 
and special; functional disorders; malformations; traumatisms; inflamma- 
tions; displacements; ectopic gestation and genital tumors. 

While much that has become obsolete is omitted, enough is retained to 
give the careful student of gynecology an idea of what has been done and 
of the progress of the science. In the consideration of the special dis- 
orders of the various pelvic structures especial effort is made to emphasize 
the influence of constitutional conditions and to impress the importance of 
the treatment from the medical side. 

Thus the acute and chronic inflammations of the uterus and of the 
peritoneum are largely rewritten. Vaccine- and serotherapy are care- 
fully considered. Early recognition, and prompt as well as radical 
treatment of cancer of the uterus are advocated. I take this opportunity 
to express my appreciation of the assistance of Dr. P. Brooke Bland in 
rewriting the microscopic diagnosis and the methods of blood-study; of 
the assistance of Miss Edith Ramsay in the preparation of the manuscript; 
of the services of Miss S. L. Clark in preparation of new sketches; and to 
the publishers for their valuable suggestions and uniform courtesy. 

E. E. Montgomery. 



Vil 



PREFACE TO FIRST EDITION 



I will offer no apology for presenting an additional text-book upon 
gynecology. 

This work has been under consideration for the last fifteen years, and 
much of it has been several times rewritten. An effort has been made to 
make it a comprehensive work upon the subject, giving the experience and 
methods of the most careful men, while my own experience has been util- 
ized to indicate that which I have found most useful and worthy of 
acceptance. 

Each general subject is considered with reference to its influence upon 
the entire genital tract, and the work is divided into sections rather than 
chapters. This course, although a departure from the ordinary text- 
book arrangement, is that which experience has demonstrated to be most 
effective in impressing the subject upon the student, and would seem to 
me preferable to him who uses the book to refresh his knowledge upon any 
particular subject. The illustrations are arranged solely with the purpose 
of rendering clear the text and to promote the work of diagnosis and treat- 
ment. For their excellence and character I am greatly indebted to the 
generosity of the publishers and to the skill and patience of their artists, 
Messrs. Shannon and Von du Lancken. To the kindly oversight of 
Dr. Robert L. Dickinson is due much of the exactness of the drawings. 
Acknowledgment is due Miss Eleanor A. Cantner for her ability in the 
preparation of preliminary sketches and of the index. 

Should it be the means of lightening the work of the student, of making 
more clear the pathway of the busy practitioner, and, most of all, of 
benefiting suffering women through improved methods of diagnosis and 
treatment, I shall feel well repaid for the many days and nights of labor 
which it has cost. 

The Author. 



IX 



CONTENTS. 



EMBRYOLOGY AND ANATOMY OF THE GENITO-URINARY 
ORGANS OF THE WOMAN. 

EMBRYOLOGY. 

Page 

1. Development of the Genito-urinary Organs i 

2. Division of the Genitaha 2 

External Genital Organs 2 

a. The Mons Veneris 2 

b. The Labia Majora 2 

c. The Labia Minora 3 

d. The Clitoris 4 

e. The Vestibule 5 

f. The Hymen 6 

g. The Fourchette 8 

3. The Muscles of the Perineum 8 

4. The Perineal Fascia 10 

5. The Pelvic Diaphragm 12 

6. Perforations 14 

7. Internal Genitalia 14 

The Vagina 14 

The Uterus 19 

The Fallopian Tubes 24 

The Ovaries 26 

The Parovarium 31 

8. Urinary Organs and Rectum 31 

The Urethra 31 

The Bladder 32 

The Ureters ^^ 

The Rectum ;^t, 

9. Pelvic Peritoneum 36 

10. Pelvic Connective Tissue 39 

11. The Vascular Supply 39 

12. The Lymphatic System 45 

13. The Consideration of the Pelvic Organs and Structure studied as a Whole .... 48 

PHYSIOLOGY. 

14. Functions 49 

15. Puberty 49 

16. Nubility 50 

17. Menstruation and Ovulation 50 

18. The Menopause 53 

19. Copulation ; 55 

20. Fecundation ■ 55 

ETIOLOGY. 

21. The Importance of Etiology 55 

22. Classification 56 

a. Hereditary and Congenital Causes 56 

b. Hygienic Causes . 58 

c. Sexual Causes 59 

d. Traumatic Causes 61 

e. Infective Causes 62 

f. Causes Incident to Age 63 

xi 



Xll CONTENTS. 

DIAGNOSIS. 

Page 

23. Difficulties in Study 64 

24. The Cultivation of Close Observation of Utmost Importance 64 

25. Exercise of Judgment 64 

26. Value of Notes 65 

27. History 65 

28. Subjective Symptoms ' . 65 

29. Causes of Error 65 

30. General or Constitutional Symptoms 66 

31. Nervous Manifestations 66 

Neuralgia 66 

Motor and Sensory Paralysis 66 

32. Disorders of Nutrition 66 

Chlorosis 67 

Anemia 67 

33. Local Symptoms 67 

34. Rectal Reflexes 68 

35. Vesical Reflexes 68 

36. Genital Symptoms 69 

2,"]. Hemorrhage 69 

38. Pain 69 

The Iliac Pain 70 

The Lumbar Pain 70 

The Hypogastric Pain 70 

The Accessory Seats of Pain 70 

The Anal or Perineal Pain 70 

The Vaginal Pain 70 

The Pelvic Pain 70 

39. Leukorrhea 70 

The Secretion from the Fallopian Tubes 71 

The Secretion of the Vagina and Vulva 71 

Other Sources of Purulent Discharges 71 

40. Physical Signs 72 

Senses Employed 72 

41. Examination 72 

42. Positions 72 

1. Dorsal Position 72 

2. Lateral Position 73 

3. Semi-prone or Sims' Position 73 

4. Genupectoral Position 73 

5. Trendelenburg Position 73 

6. Erect Position 74 

43. Preliminaries 75 

44. Inspection of the Abdomen 76 

45. Palpation 77 

46. Percussion 78 

47. Auscultation 78 

DIGITAL EXAMINATION. 

48. Examination of the Pelvis . 79 

49. Digital Examination 79 

50. Bimanual Procedure 80 

Difficulties 82 

Virgins 83 

51. Rectal Touch 7 83 

INSTRUMENTAL EXAMINATION. 

52. Instrumental Examination 85 

53. Probes 86 

Precautions . . . , 87 

54. Specula 88 

The Tubular Speculum 88 

The Valvular Speculum 89 

The Univalve or Duck-bill Speculum 90 



CONTEXTS. Xlll 

Page 

55. Uterine Fixation and Downward Traction 92 

56. Dilatation of the Uterus 92 

Dilatation by Tents 92 

Divulsion 95 

Gradual Dilatation 96 

Dilatation by Gauze Packing 96 

Incision of the Cervix 96 

Complete Bilateral Incision of the Cervix 97 

EXPLORATION OF THE URETHRA, BLADDER, AND URETERS. 

57. The Bladder 98 

EXPLORATORY OPERATIONS. 

58. Explorator}' Operations 103 

Tapping or Paracentesis Abdominis 103 

Aspiration 104 

Exploratory- Incision 104 

MICROSCOPIC EXAMINATION. 

59. ^Microscopic Examination 105 

60. Collection of Tissue 105 

Test Excision 105 

Test Curetment 106 

61. Disposition of Tissue 108 

62. Examination 108 

63. Preservation of Gross Specimens and Slides 113 

64. Failure 115 

65. Bacteriolog}' of the Genital Tract . . ; 115 

66. Parasites 116 

67. Natural Agents of Immunity 117 

68. Loss of Protection 117 

69. Parasites, Classification of 117 

\^egetable 117 

Animal 118 

70. Staphylococcus 118 

71. Streptococcus ' 119 

72. Gonococcus 120 

73. Bacillus Coli Communis 123 

74. Bacillus Tuberculosis 123 

75. Syphilis and Chancroid 125 

76. Bacillus Typhosus 127 

77. Smegma Bacillus 127 

78. Bacillus Pyocyaneus 127 

79. Bacillus Aerogenes Capsulaius 128 

80. Diphtheria Bacillus 128 

81. Pneumococcus 128 

82. The Diplococcus of Siegelman 128 

83. Collection of Fluids and Secretions 128 

ANIMAL PARASITES. 

84. Pediculosis Pubis or Inguinalis 130 

85. Acarus Scabiei 130 

86. Ox}-uris Vermicularis 130 

87. Ascaris Lumbricoides 130 

88. Taenia Echinococcus 130 

BLOOD EXAMINATION. 

89. The Blood 131 

90. Leukocytes 133 

91. Bacteremia 133 

Bacteria Found in Blood 134 

92. Blood Culture 134 



XIV CONTENTS. 

THERAPEUTICS. 

Page 

93. Classification j^^ 

94. Medical Treatment ' 174 

95. Specific Remedies 136 

96. Rest and Exercise 127 

97. Baths .... 138 

98. The Sheet Bath and Wet Pack 138 

99. The Nauheim Bath i^g 

100. The Hot Air Bath 140 

loi. The Electric Light Bath 140 

102 Sea Bathing 140 

103. The Sitz Bath 140 

104. General Massage 141 

105. Pelvic Massage 141 

106. The Douche 142 

107. External Applications 143 

108. Counterirritants 143 

ICQ. Blood Letting 143 

no. Local Applications 144 

Various Agents 144 

Caustics 145 

111. Tampons 145 

112. Pessaries 146 

113. Electricity 150 

114. The Static Current 150 

115. The Induced, or Faradic, Current 150 

116. The Sinusoidal Current 151 

117. The Continuous Current 151 

118. Rontgen 151 

119. Contraindications 152 

120. The Finsen Light 153 

121. Electrocautery and Light 153 

122. Radium . . . • 154 

123. Infection 155 

Terms 155 

124. Methods of Sterilization 155 

125. Instruments 156 

126. Sponges 157 

127. Ligature and Suture Material 158 

128. Dressings 160 

129. Personal Cleanliness 160 

130. The Room and Environment 161 

131. In the Preparation of the Patient . 162 

Special Preparation 162 

132. Irrigating Tubes 163 

133. Gauze 163 

134. Antisepsis of the Crevix and Uterine Cavity 164 

135. The Use of Tents 165 

136. Abdominal Section 165 

137. General Anesthesia 165 

138. Local Anesthesia 168 

139. Spinal Anesthesia 169 

140 Preliminary Details of Operation 169 

141. Arrangement 170 

142. Positions of Operator and Assistants 170 

143. The Patient's Clothing 170 

144. Incision 170 

145. Adhesions 173 

146. Toilet of the Peritoneum 174 

T47. Drainage 175 

Objections 176 

Gauze Drain 177 

Where Placed 177 

Postural Drainage 178 

148. Closure of the Wound 178 



CONTENTS. XV 

Page 

140. Dressing . 180 

150. Postoperative Treatment 180 

151. Comfort of Patient 181 

152. Vomiting :■ 182 

153. Tympanites 183 

154. Shock 183 

155. Anodynes 183 

156. Internal Hemorrhage 184 

157. Peritonitis '. 184 

158. Wound Infection 185 

159. Parotiditis 185 

160. Ileus 185 

161. Phlebitis 186 

162. Precautions in the Use of the Hypodermic Syringe 186 

163. Catheterization 187 

164. Removal of Sutures 187 

165. Leaving the Bed 188 

166. In Plastic Operations 188 

FUNCTIONAL DISORDERS. 

167. Menstruation 188 

168. Vicarious Menstruation 189 

169. Amenorrhea 190 

170 Menorrhagia 192 

171. Dysmenorrhea 193 

172. Copulation 195 

173. Vaginismus 196 

174. Sterility 197 

MALFORMATIONS. 

175. Definition and Classification 200 

176. Bifidites 201 

177. The Degrees of Division 201 

178. Double Uterus 201 

179. Unequal Development of the Two Sides 203 

180. Absent Uterus 204 

181. A Rudimentary Uterus 204 

182. In Fetal and Infantile Uteri 205 

183. Treatment of Uterine Malformations 205 

184. Absent or Rudimentary Tubes 206 

185. Absence of Ovaries 206 

186. Extra Ovaries 207 

187. Accessory of Constricted Ovaries 207 

188. Round and Broad Ligaments 207 

189. Absent or Rudimentary Vagina 207 

190. Double Vagina 210 

191. Atresia of the Genital Canal 210 

192. Defects of the Vulva 215 

193. Defects in Nymphae 215 

194. Defects of the CHtoris 215 

195. Defects of the Hymen 216 

196. Hermaphroditism 217 

Pseudohermaphroditism . 218 

Gynandria 219 

Androgyna 219 

197. Hypospadias 220 

198. Epispadias 220 

Duphcation of the Bladder 221 

199. Irregular Exit of Ureter 221 

200. Abnormal Communications 222 



XVI CONTENTS. 

TRAUMATISMS. 

Page 

201. Injuries of the Genital Organs 223 

202. External Violence 223 

203. Coition 225 

204. Parturition 226 

205. Injuries of the Body of the Cervix 226 

206. Injuries of the Cervix Uteri 227 

207. Trachelorrhaphy 231 

208. Amputation of the Cervix 233 

After-treatment 234 

209. Lacerations of the Vagina 234 

FISTULA. 

210. Fistulse 236 

Etiology 236 

Symptoms - 236 

Diagnosis 237 

Prognosis 239 

Treatment 239 

Cauterization 239 

Prehminary Treatment 240 

211. Vesicovaginal Fistula 241 

212. Flap SpHtting or Flap SUding 243 

213. Flap Formation 248 

After-treatment 250 

214. Closure of the Vagina, Colpocleisis, Espisiostenosis 251 

215. Urethrovaginal Fistula 252 

216. Vesicouterine Fistula 252 

217. Hysterostenosis or Hysterocleisis 253 

218. Vesico-utero vaginal (Cervical) Fistula 254 

219. Ureterovaginal-ureterocervical Fistulae 255 

220. Accidents of the Operation and Results 260 

221. Rectovaginal Fistula 261 

222. An Anovulvar Fistula 262 

223. Enterovaginal Fistulse 263 

224. Cervicovaginal Fistula 263 

PERINEUM. 

225. Lacerations of the Pelvic Floor 264 

Causes 265 

Degree or Extent 266 

Results 267 

Treatment 268 

By Primary Operation 268 

The Advantages of Primary Procedure 270 

Contraindications 270 

The Immediate Operation 270 

Secondary Operation 270 

226. Operations on the Pelvic Floor 271 

Choice of Operation 296 

After-treatment 297 

INFLAMMATIONS. 

227. Recognition of the Development of the Genital Tract 298 

228. Micro-organisms 298 

229. Inflammation 298 

The Causes of Inflammation 299 

Characteristics of Inflammation 300 

230. Classification 301 

231. Vulvitis 302 

Causes 302 

Simple or Catarrhal Vulvitis 302 

Follicular Vulvitis 303 

Venereal Vulvitis 303 



CONTENTS. XVll 

Page 

232. Eruptive Diseases of the Vulva 304 

Phlegmonous Vulvitis 305 

Diphtheric Vulvitis 305 

Diagnosis of Inflammatory Disorders of the Vulva 305 

Treatment 306 

233. Edema and Gangrene 308 

234. Bartholinitis 308 

235. Pruritus Vulvae 310 

236. Kraurosis Vulvae 312 

237. Urethritis 314 

Hyperemia 314 

Acute Catarrhal Urethritis 315 

Chronic Catarrhal Urethritis 315 

Follicular Inflammation 315 

Ulceration 316 

Vesico-urethral Fissure 316 

Diagnosis of Urethral Inflammation 317 

Treatment of Urethral Inflammation 318 

238. Cystitis 319 

Symptoms of Acute Cystitis 320 

Symptoms of Chronic Cystitis 321 

Cystitis of Gonorrheal Origin 321 

Tubercular Cystitis 321 

Diagnosis of Cystitis 322 

The Prognosis of Cystitis 325 

Treatment 325 

239. Ureteritis 329 

Acute Ureteritis 330 

Chronic Ureteritis 330 

240. Vulvovaginitis 331 

241. Vaginitis, Elytritis or Colpitis 332 

Varieties 333 

Pathology 334 

Etiolog}' 334 

Symptoms 335 

Diagnosis 335 

Prognosis 336 

Treatment 336 

CERVIX AND BODY OF UTERUS. 

242. Inflammation of the Cervix and Body of the Uterus 337 

243. Endocervicitis — Chronic Cervical Catarrh 338 

Causes 341 

Symptoms 342 

Physical signs 342 

Diagnosis 343 

Prognosis 343 

Treatment 343 

244. Acute ^Metritis and Endometritis 346 

Pathologic Alterations 346 

Varieties and Their Source 347 

Symptoms 347 

Diagnosis 349 

Prognosis 350 

Treatment 351 

245. Chronic Endometritis 355 

Symptoms 357 

Diagnosis 358 

Treatment 359 

246. Chronic Metritis 361 

Etiology 362 

Symptoms 363 

Physical Signs and Diagnosis 364 

Course and Prognosis 365 

Treatment 365 



XVlll CONTENTS. 

Page 

247. Inflammation of the Fallopian Tube 370 

Physical Signs 376 

Diagnosis 377 

Prognosis 377 

248. Inflammation of the Ovary 378 

Symptoms 381 

Diagnosis 382 

Treatment of Inflammation of the Appendages 382 

249. Pelvic Inflammation 385 

Varieties 386 

250. Pelvic Celluhtis, Parametritis, or Peri-uterine Phlegmon 386 

Etiology 387 

Symptoms : 388 

Physical Signs 388 

Diagnosis 391 

Prognosis 392 

Treatment 393 

251. Pelvic Peritonitis, Perimetritis, Perisalpingitis or Perioophoritis 394 

Etiology ^ 394 

Pathologic Anatomy 397 

Symptoms 399 

Diagnosis 400 

Prognosis 401 

Treatment 402 

DISPLACEMENTS OF THE PELVIC ORGANS. 

252. Displacements of the Pelvic Organs 417 

Physiologic Movements of the Uterus and Forces by Which it is Sustained . . 417 

Pathologic Changes and What Constitute Them 419 

Classification of Displacements 42 1 

253. Ascent 421 

Diagnosis 422 

254. Descent, or Prolapsus 422 

Etiology 424 

Symptoms 428 

Diagnosis 43° 

Prognosis 434 

Treatment 437 

255. Urethrocele .- 447 

256. Dislocation of the Uterus 44^ 

Diagnosis 44^ 

257. Torsion 44^ 

258. Anteversion 449 

Etiology 449 

Symptoms 45° 

Diagnosis 45° 

Treatment 45° 

259. Retroversion 45 J"^ 

Etiology 452 

Symptoms 452 

Diagnosis 453 

260. Lateral Version 453 

261. Anteflexion 454 

Etiology 455 

Symptoms 455 

Diagnosis 455 

Treatment • 45^ 

262. Retroflexion 459 

Etiology 460 

Symptoms 460 

Diagnosis 4^4 

263. Treatment of Retroversion and Retroflexion 466 

264. Lateral Flexion 4^8 



CONTENTS. ' XIX 

Page 

265. Complications Associated with Displacements 488 

Prognosis of Displacements 489 

General Treatment 489 

Summary 490 

266. Inversion of the Uterus 492 

Etiology 494 

Symptoms 495 

Diagnosis 496 

Treatment 498 

267. Displacement of the Appendages 505 

Symptoms . 506 

Diagnosis 506 

Treatment . 506 

268. Genito-urinary Hemorrhage 506 

Site and Varieties 507 

269. Hematuria 507 

Symptoms and Diagnosis 507 

Treatment 508 

270. Genital Hemorrhage or Bleeding 509 

Diagnosis 509 

Treatment 511 

271. Vulvar Hematoma, Hematocele, or Thrombus 512 

272. Vaginal Hematoma or Thrombus 513 

Diagnosis 514 

Treatment 514 

273. Peri-uterine Hemorrhage 514 

Causes 515 

Symptoms 515 

274. Extraperitoneal Hematocele 516 

Symptoms 516 

Diagnosis 517 

Prognosis 518 

Treatment 518 

ECTOPIC GESTATION. 

275. Ectopic Gestation 520 

Causes 520 

Varieties 521 

Course and Progress 523 

Symptoms 536 

Diagnosis 538 

Differential Diagnosis 542 

Prognosis 545 

Treatment 546 

GENITAL TUMORS. 

276. Genital Tumors 556 

Classification 556 

277. Characteristics of Benign Neoplasms 558 

278. Hernias 558 

279. Hydrocele 559 

280. Urethral Growths 561 

Urethral Caruncle 561 

281. Varicose Veins of the Vulva 563 

282. Edema 564 

283. Elephantiasis . 564 

THE VULVA. 

284. Tumors of the Vulva 564 

285. Cysts 564 

Serous Cysts 564 

Sebaceous Cysts 564 

Blood Cysts 564 

Neuroma of the Vulva 565 



XX CONTENTS. 

Page 

286. Simple Vegetations 565 

287. Fibroma and Myxoma ^67 

288. Lipoma 568 

289. Enchondroma 568 

290. Malignant Disease of the Vulva ^68 

THE BLADDER. 



291. Tumors of the Bladder ^^i 

292. Papilloma ^72 

293. Carcinoma 572 

294. Adenoma 572 

295. Sarcoma 572 

296. Myoma 573 

THE VAGINA. 

297. Cysts of the Vagina 579 

298. Fibroid Tumors and Polypi 580 

299. Papillomata 581 

300. Malignant Neoplasms 582 

THE UTERUS. 

301. Myofibromata 584 

Pathologic Anatomy 585 

Microscopic Appearance ■ 585 

Varieties 585 

302. Submucous Fibroids 587 

303. Interstitial, Mural or Centric Fibroid Growths 590 

304. Subperitoneal Growths ' . 594 

305. Fibromyoma of the Cervix 595 

Etiology 597 

Symptoms 598 

Diagnosis of Myomata 602 

306. Differential Diagnosis of Myomata 604 

307. Alterations and Degenerations 610 

308. Mixed Growths — -Enchondroma, Sarcoma, Osteoma, and Carcinoma 615 

309. Complications 615 

The Influence of Myoma upon Conception ^617. 

The Influence of Pregnancy upon the Myoma 618 

The Influence of the Myoma upon Pregnancy 619 

Influence upon Labor 619 

Course and Prognosis . 620 

310. Treatment 623 

Medical Treatment 624 

Electrical Treatment 626 

Surgical Treatment 629 

311. Vaginal Procedures 630 

1. Dilatation of the Uterus 630 

2. Incision of the Cervix 631 

3. Incision of the Capsule 632 

4. Removal of the Growth 633 

5. Ligation of the Vessels 639 

6. Hysterectomy 640 

312. Abdominal Route 641 

7. Castration 641 

8. Ligation of the Vessels 642 

9. Myomectomy 643 

10. Enucleation • 644 

11. Partial Hysterectomy or Supravaginal Amputation of the Uterus 645 

12. Panhysterectomy 650 

Summary 656 

313. Accidents during Operation 658 

314. Causes of Death Following Hysterectomy 661 



CONTENTS. XXI 

PUERPERAL TUMORS. 

Page 

315. Physometra 662 

316. Hydrometra 662 

317. Hematometra 662 

318. Pyometra 662 

319. Hydatid Cysts of the Uterus .- 662 

320. Mucous Polypi of the Uterus 663 

321. Malignant Tumors 664 

Pathologic Classification 664 

Anatomic Classification of Carcinoma 665 

322. Development of Squamous-cell Carcinoma 666 

Histology of Squamous-cell Carcinoma 668 

323. Adenocarcinoma of the Cervix 669 

Histology of Adenocarcinoma 670 

324. Adenocarcinoma in the Body of the Uterus 671 

Histology of Adenocarcinoma in the Body of the Uterus 673 

325. Dissemination of Carcinoma 675 

Clinical Forms 679 

Etiology * 683 

Symptoms 685 

Physical Signs 689 

Complications 690 

Diagnosis 692 

Duration of Cancer 697 

Prognosis 697 

Treatment 698 

326. Radical Operations 699 

Partial Extirpation of the Vagina 699 

Total Extirpation of the Uterus 701 

Vaginal Hysterectomy 704 

Accidents of Vaginal Total Extirpation 710 

Abdominal Hysterectomy 712 

Comparative Advantages of the Two Proceedings 717 

The Sacral Method 718 

The Perineal Method 724 

The Mortality of Abdominal and Vaginal Operations 725 

Duration of Recovery 725 

Recurrence 726 

327. Palliative Operations 728 

J?8.' Pregnancy Complicating Carcinoma 738 

329. Summary 739 

330. Chorio-epithelioma Mahgnum 740 

331. Endothelioma Uteri 746 

332. Sarcoma Uteri 747 

Varieties 747 

Pathology 747 

Etiology 751 

Symptoms 752 

Duration 754 

Diagnosis 755 

Recurrence 758 

Treatment 759 

S33. Treatment Following Operations for Mahgnant Disease 759 

FALLOPIAN TUBES. 

334. Benign Tumors or Growths of the Fallopian Tubes 761 

Fibroma or Myoma 761 

Fibrocyst 761 

Enchondromata 761 

Dermoid of the Tube 761 

Cysts of Small Size 761 

Polypus 762 

Papillomata 762 

335. Malignant Tumors 763 

Sarcoma 763 

Chorio-epitheKoma Malignum 764 



XXll CONTENTS. 

THE BROAD LIGAMENT. 

Page 

336. Cysts of the Broad Ligament 764 

Echinococcus Cysts 764 

Parovarian Varicocele, Phleboliths 765 

Lipomata 765 

Fibroma 766 

337. Malignant Growths 766 

OVARIAN TUMORS. 

338. Ovarian Tumors. Characteristics 766 

Classification • 766 

Small Residual Cysts 768 

Simple or Follicular Cysts; Hydrops Folliculorum 769 

Cysts of the Corpus Luteum 770 

Tubo-ovarian Cysts 770 

339. Glandular ProUf crating Cysts 771 

The Attachment ., 772 

Structure 776 

340. Papillary Proliferous Cysts 778 

341. Dermoid Cysts 780 

342. Parovarian Cysts 781 

343. SoUd Ovarian Tumors 782 

Fibromyoma 782 

Sarcoma of the Ovary 784 

Carcinoma of the Ovary 784 

Endothelioma of the Ovary 784 

Etiology 784 

Natural Progress 785 

Symptoms 786 

CompUcations 786 

Degenerative Changes in the Cyst-walls 793 

Diagnosis 793 

Exploratory Puncture 804 

Exploratory Incision 805 

Treatment 805 

344. Ovariotomy 806 

Indications 806 

Contraindications • • 807 

General Considerations 807 

The Operation 809 

Incomplete Operation 817 

Rupture of the Cyst 818 

Hemorrhage 818 

Visceral Injuries 819 

Prognosis • " 821 

Intestinal Complications 821 

Causes of Death 822 



PRACTICAL GYNECOLOGY. 



EMBRYOLOGY AND ANATOMY OF THE GENITO -URINARY 
ORGANS OF THE WOMAN. 

I. Development of the Genito-urinary Organs. For a proper 
understanding of the conditions in which the genito-urinary organs fail 
to attain the normal, a knowledge of their origin and development is 
necessary. 

Their normal progress in the embryo may be divided into five stages : 

The first period extends to the eighth week. After fecundation, no 
sexual indication is manifest before the fifth week. A primordial kidney, 
Wolffian body, duct of Miiller and Wolffian duct, from which the genital 
organs originate, develop on each side of the median line. At the site 
of the future vulva, a cloaca is situated, into w^hich the urachus and 
intestine open. On the external surface of each Wolffian body a structure 
develops known as the genital gland. Subsequently this forms either 
the testicle or ovary. Simultaneously the cloaca becomes divided by a 
projection — the genital eminence or tubercle — and the latter is marked by 
the genital furrow or groove. The appearance of these structures at the 
eighth week affords no clue as to the probable sex. 

The second period lasts from the eighth to the twelfth week. The 
Miillerian ducts coalesce and for the lower two-thirds of their extent the 
septum disappears. The point of division between the tube and the uterus 
is indicated by the insertion of the round ligament. The cloaca under- 
goes further change which, by the development of the perineum, is divided 
into two portions; the urogenital sinus and the anus. 

The third period, the twelfth to the twentieth week, witnesses the 
fusion of the uterine horns; the appearance of the arbor vitae in the uterine 
cavity; formation of the cervix; enlargement of the perineum; and develop- 
ment of the vagina which opens into the urogenital sinus and forms the 
vaginal vestibule in which the hymen appears. The genital tubercle, 
which heretofore has been large, is reduced to the proportions of the clitoris, 
and the edges of the genital fissure become the nymphse. 

The fourth period extends from the twentieth week to the end of fetal 
life. During this period the fundus of the uterus increases in size; the 
mucous membranes of the vagina and cervix become folded, and the labia 
majora grow fuller and more rounded. 

The fifth period comprises from the time of birth until puberty. The 
uterus increases in size and thickness; the uterine mucous membrane, 
which prior to the sixth year is folded like that of the cervix, becomes 



GYNECOLOGY. 




3 

— 4 

S 



smooth. The vagina is elongated, and the vulva is larger and more 
rounded. 

2. Division of the Genitalia. The special generative organs of the 

woman occupy the pelvis in close asso- 
ciation with the bladder, urethra, rec- 
tum, and anus. The female genitalia 
comprise two classes of organs, the 
external and the internal. The former 
with the vagina form the organ of 
copulation, the latter the reproductive 
organs proper. 

The external genital organs as enu- 
merated from before backward com- 
prise the mons veneris, labia majora, 
labia minora, clitoris, vestibule (per- 
forated by the meatus urethrae exter- 
nus) , orifice of the vagina (surrounded 
in the virgin by the hymen) , f ourchet, 
fossa navicularis, and perineum — the 
latter situated between the vulva and 
anus. The external genitalia are also 
named vulva, pudendum, or cunnus; 
and the cleft between the labia majora, 
the rima pudendum. 

2a. The mons veneris is a cushion 
of fat situated over the pubes. It is 
covered with thick skin abundantly 
supplied with hair which protects the 
vulva from the perspiration of the 
body. When the nude woman is 
erect, the mons veneris is the portion 
of the genitalia visible. 

2b. The labia majora are skin 
folds which, in front, merge into the 
mons veneris. Posteriorly they thin off 
and terminate about one and one-half 
inches in front of the anus. Exter- 
nally they are covered with short, crisp 
hair which is continuous with that of 
the mons veneris. They are profusely 
supplied with sebaceous and sudorif- 
erous glands. Their surfaces present 
a smooth, moist surface which resem- 
bles mucous membrane. The apposi- 
tion of the labia majora, slightly sepa- 
rated by the labia minora and clitoris, forms a cleft of the vulva, the rima 
pudendum. Each labium contains a sac-like structure called the dartoid. 
This is analogous to a similar structure in the male scrotum. The round 




wM^^m 



i8 19 i8 

Fig. I. — Human Embryo at End of 

Thirty-five Days. (Coste.) 
. Tongue. 2. Aortic bulb. 3. First 
permanent aortic arch. 4. Second 
aortic arch. 5. Third aortic arch, 
or ductus Botalli. 6. The two fila- 
ments to the right and left of this 
figure are the pulmonary arteries. 
7. The trunk of the superior vena 
cava and the right azygos vein. 8. 
The common venous sinus of the 
heart, 9. Left auricle of the heart. 
10. Right ve itricle. 11. Left ven- 
tricle. 12. Lungs. 13 Stomach. 
14. Left omphalomesenteric vein. 
15. Wolffian body. 16. Right 
omphalomesenteric vein. 17. Intes- 
tine. 18, 18. Umbilical arteries. 
10. Umbilical vein. 



EMBRYOLOGY. 



ligament, and, in the fetus, an open canal called the canal of Nuck, ter- 
minates in this dartoid sac. Occasionally the latter remains open in the 
woman, permitting the formation of a hydrocele. In fat subjects these 
folds contain a large quantity of adipose cellular tissue. 




Fig. 2. — Coalescence of Miiller's Duct. 



2c. The labia minora are situated between the labia majora slightly 
projecting beyond their level, and more prominent anteriorly. Upon 
wide separation they are seen to be continuous with the fourchet and form 
the posterior commissure. Anteriorly they bifurcate and form two folds: 





Progress of Development of the Genitalia. 



Fig. 3.— All. Allantois. R. 
Rectum. M. Muller's 
duct. X. Indentation 
of the skin which forms 
the anus. {Schroder.) 



Fig. 4-— CI. Cloaca. B. 
Bladder. R. Rectum. 
V. Vagina. {Schroder.) 



Fig. 5. — Su. Urogenital si- 
nus. R. Rectum, sepa- 
rated from the foimerby 
the perineum B. Blad- 
der. V. Vagina. u. 
Urethra. {Schroder.) 



the anterior one passes in front of the clitoris to form its prepuce or hood, 
the posterior one passing behind the glans clitoris and forming the frenu- 
lum. The labia minora (also called the nymphae) have a slightly rough- 
ened surface with free, convex borders, sometimes notched. Frequently 



4 GYNECOLOGY. 

small openings or perforations are seen. The" size of the nymphae varies 
greatly according to the race and age of the subject. They project con- 
siderably beyond the vulva in the young child, but, owing to the increase in 
size of the labia majora as puberty approaches, they are rendered less 
apparent. In the Bushwomen the labia minora frequently become so 
long that they reach to the knees, and are then spoken of as the Hottentot 
apron. The skin is covered with stratified pavement epithelium, similar 
to that of the true epidermis. They are plentifully supplied with seba- 






FiG. 6. — ^Virgin Vulva; Labia not Separated. {From Deaver.) 

ceous glands, especially at the base of the folds where they form a crowded 
layer upon the inner surface. In the brunette the pigment deposit fre- 
quently is so great as to make them noticeably dark. The skin folds con- 
tain a small amount of connective tissue. During the act of coition the 
labia minora hold the glans clitoris against the male organ. 

2d. The clitoris, as in the male is an erectile organ, formed by a crus 
clitoris or corpus cavernosum arising on either side from the posterior 
surface of the ischio pubic rami, which unite to form one body in front 



EMBRYOLOGY. 5 

of the symphysis. The organ is secured to the symphysis by a suspensory 
ligament, and its circulation is influenced by the ischi-cavernosus muscle, 
in which respect it resembles the penis. The corpora cavernosa are en- 
veloped by a fibrous investment and separated by a median septum of cav- 
ernous tissue composed of fine trabeculae, in which the muscular elements 
predominate. The free extremity of the clitoris is situated at the anterior 
part of the vulva, about one-half inch behind the anterior extremities of 
the labia majora. The organ is surmounted by a median tubercle known 
as the glans clitoridis. The glans is more or less covered by the prepuce 
formed by the anterior folds of the labia minora or nymphae. The glans 




Fig. 



irgin 



\ulva: 



Labia Separated, Showing the Hymen Unruptured. 
{From Deaver.) 



is imperforate and generally is but slightly developed. When the clitoris 
is large, the other parts of the vulva generally are found small and ill de- 
veloped. 

2e. The vestibule is described by some anatomists as the entire space 
between the labia minora, which, prior to the rupture of the hymen, in- 
cludes the external surface of the latter. But, as this portion disappears 
largely after successful coition, and completely after parturition, it seems 
better to confine the term to the portion ordinarily so denominated. 
This has for its boundaries the labia minora on each side, and the anterior 
border of the vagina posteriorly. The triangular space thus formed has 
the glans clitoridis for its apex; and, at its centre, near the posterior 



6 GYNECOLOGY. 

border, is a rounded pouting orifice — the meatus urethrae externus. Two 
clusters of large mucous follicles also have the openings of their ducts in 
this situation. One of the group lies immediately behind the clitoris, and 
when its ducts become occluded, a cyst is formed. The other is situated 
near the meatus. Mucus is secreted very freely by these follicles under 
any persistent local irritation. In the virgin, a grooved ridge is seen, which, 
according to Pozzi, represents the corpus spongiosum of the male and is 
known as the vestibular band. Behind the clitoris in the posterior part 
of the vestibule and about one inch in front of the fourchet is situated the 
orifice of the meatus urethrae. Ordinarily it presents a longitudinal or 
starred slit, the borders of which are slightly notched and projecting. 
Occasionally its mucous membrane bulges, forming a ring-like margin. 





Fig. 



-Hymen Crescens. 



Fig. 9. — Hymen Annularis. 



Within the elevated margins of the meatus, and slightly posterior to its 
center, is found a minute opening on each side. These are the orifices 
of Skene's ducts, which are parallel to the urethra and about 2 cm. 
in length. Usually they are not detected easily in healthy subjects, 
but following gonorrhea or leukorrhea are recognized readily. Under 
such circumstances, they are sometimes so large that a catheter may 
enter one of the canals instead of the orifice of the urethra. A patient 
recently came under my observation in whom the external openings were 
occluded and projected on either side of the urethra partially obstructing it. 
2f. The hymen is a thin membrane acting as a sort of diaphragm be- 
tween the internal genital parts, the external genital parts, and the orifice 
of the urethra. It is revealed by separation of the labia minora (Fig. 7). 



EMBRYOLOGY. 7 

Its exterior surface resembles the structure of the latter, while the interior 
frequently presents the rugag of the vagina. When the labia are not for- 
cibly separated, the hymen appears as a vertical slit with its lateral edges 
in contact. With the labia held apart however, the opening is usually 
crescentic with its concave margin anterior. (Fig. 8.) Sometimes 
it is annular with a central opening. (Fig. 9.) The hymen may present a 
variety of forms and openings, such as the labial form, in which the lateral 
folds may be mistaken for the labia minora; the linguiformis, which pre- 
sents a tongue-shaped projection posteriorly, and the falciform, which 
has a somewhat long and wide orifice. The free edge of the hymen may 
be smooth, denticulated, or serrated. (Fig. 10.) Its structures may be 
thick and fleshy, and present irregular folds resembling fimbriae. The 





Hvmen Serralus. 



Fig. II. — H\men Infundibularis. 



infundibular form (Fig. 11) presents a funnel-shaped appearance with 
the margins looking downward and backward. There may be two open- 
ings, the septus or biseptus (Fig. 12), or a number of openings, as the crib- 
riform. (Fig. 13.) The hymen guards the entrance of the vagina; usually 
ruptures during the first coition, and occasionally its tear is followed by 
profuse and often dangerous bleeding. (Fig. 14.) The membrane 
is usually thin and easily torn, but occasionally it is so firm that it with- 
stands the most strenuous efforts of coition, and, therefore will require 
incision before the sexual act can be accomplished. The greater portion 
of the hymen is destroyed during the process of parturition, the remainder 
shrinking together to form small masses at the vaginal outlet. These 
masses are known as the carunculae myrtiformes. The number, form, 
and situation of these caruncles varv extremelv. Generallv there are three. 



8 



GYNECOLOGY. 



One is situated at the posterior part, the others at the sides of the entrance 
to the vagina. Both surfaces of the hymen are covered with pavement 
epithelium. 

2g. The fourchet is a continuation backward of the labia minora in 
the form of a thin fold, and is rendered prominent by the separation of the 
vulva. Between this fold and the hymen is a boat-shaped depression 
called the fossa navicularis. Between the fourchet and the anal opening 
is an intervening space covered with integument, some 4 cm. in length. 
This is called the perineum. 

3. The Muscles of the perineum are exposed by the removal of 
the skin, the superficial fascia, and a layer of the deep fascia. The 
muscles thus mapped out are: The erector clitoridis; the hulhocavernosus 





Fig. 12. — Hymen Biseptus. 



Fig. 13. — Hymen Cribriformis. 



and the transversus perinei, paired muscles; and the sphincter ani and 
levator ani, which are single. The erector clitoridis arises from the ante- 
rior margin of the rami of the pubes and ischium and is inserted by two 
tendonous expansions, one above the junction of the crura into the body of 
the clitoris, and the other below and in front. The bulbocavernosi 
muscles arise from the tendinous raphe and anterior aponeurosis of the 
perineum, and are separated by the vagina, around which they course, to 
be inserted by a thin slit into the crus of each side in front of the erector 
clitoridis. The outer fibers of the muscle wind inward beneath the erector 
muscles to reach the upper part of the bulb near its isthmus. A portion 
of the mediam fibers are apparently derived from the sphincter and pass up- 
ward to the clitoris, over the pubes, and are lost in the superficial fascia. 



EMBRYOLOGY. 



Other fibers form a delicate muscular arch in front of the body of the cli- 
toris. The action of the muscles is to compress the bulb of the vagina and 
to some degree act as a sphincter of the vagina though Savage assigns the 
latter function to a portion of the levator ani. The relation of a portion of 
the fibers to the sphincter ani produces a figiire-of-8 action upon the two 
orifices, which it is important to remember in operations upon the sphincter. 
The transversus perinei muscles arise. one on each side from the tuberosity 
of the ischium, and are attached to the anterior aponeurosis of the perineal 
septum, the perineal body, and the skin of the perineum in front of the 
anus. The sphincter ani arises from the tip 
of the coccyx and is attached in front to the 
tendinous raphe of the perineum, where it 
meets the fibers of the bulbocavernosi. Its 
fibers, closely attached to the skin, decus- 
sate in front of the anus, while some fibers 
appear to pass completely around it. The 
muscle is pierced by radiating fibers from 
the longitudinal muscular coat of the rec- 
tum, and is in close relation with the levator 
ani and internal sphincter. This muscle 
forms the external sphincter and is volun- 
tary in its action. The levator ani is the 
principal muscle of the pelvic floor. It 
arises from the back of the body and hori- 
zontal ramus of the pubes, the pelvic fascia 
(white line), and the spine of the ischium. 
From its origin the muscle sweeps down- 
ward and inward and is attached in the 
middle line from before backward as follows: 
To the vagina, to the rectum, to its fellow 
of the opposite side, and, finally, to the tip of 
the coccyx. The pubic fibers blend with 
the posterior half of the upper border of 
the sphincter vagince 




Fig. 



14- 



Laceration of the 
Hymen. 

This muscle is more readily exposed from above. 
The vulvovaginal gland and the bulb of the vestibule are exposed in 
the dissection already described. The former is a racemose gland, 
situated on either side of the vagina and posterior to its orifice. It is analo- 
gous to Cowper's gland in the male. It is also known as the vulvar 
gland of Bartholin, or, according to Huguier, the vulvovaginal gland. 
It is about the size of an almond, but varies in different individuals even 
upon the two sides. Occasionally glandular nodules are seen, which 
seem to be detached from the gland and scattered in the surrounding 
muscle. Within, the gland is in close relation with the vagina, to which 
it is adherent by tense cellular tissue, while externally it lies beneath the 
bublbocavernosus muscle. Its excretory duct, about i cm. long, is 
directed from below upward and from without inward and opens in the 
angle between the hymen and the wall of the vulva. When the hymen has 
disappeared, its orifice is found in the corresponding angle between the 



lO 



GYNECOLOGY. 



carunculae myrtiformes and the wall of the vulva. It is usually difficult 
to detect, but sometimes presents an orifice which will admit a probe. 
This gland furnishes the secretion which is manifest under the influence 
of sexual excitement or during coition. The bulb of the vestibule is a 
venous mass which is situated along each side of the vagina and the vesti- 
bule. It is related within to the vagina, vestibule, and urethra, and is 
covered externally by the bulbocavernosus muscle. The bulbs unite be- 
neath the clitoris by a venous connection, the pars intermedia. Kobelt 
says the injected bulb is nearly 4cm. long, icm. wide, and from 9/10 to 
i/io cm. thick. Its external surface is convex; its internal surface 




concave. The bulb is a part of the erectile tissue of the female genital 
organs analogous to the corpus spongiosum in the male. 

4. The perineal fascia or the fascia of the pelvic floor consists 
of the following: 

a. The superficial fascia. 

b. A deep layer of the superficial fascia. 

c. The triangular ligament, composed of two layers. 

a. The superficial fascia is a continuation of the general fascia of the 
body. It consists of two layers. The outer more or less loaded with fat, is 
continuous with the same layer over the buttocks, thighs, and abdomen. 



EMBRYOLOGY. II 

The inner, the peritoneal septum, a more resisting membranous investment 
descends from the abdomen, narrowed to the width of the pubes, but 
spreading out so as to envelop the anterior perineal triangle at its base. 
The abdominal portion of the fascia is firmly adherent to Poupart's liga- 
ment; the perineal portion to the outer margin of the ischiopubic rami 
and the inferior margins of the septum; while the pubic portion is attached 
along a curved line of the bone, which indicates the origin of muscles of 
the anterior part of the thigh. 

b. A tubular prolongation known as the pudendal sac, extends back- 
ward from the margin of the external inguinal ring on each side of the 
vagina, nearly to the posterior vulvar commissure. With its fellow of 
the opposite side, when enveloped with their cutaneous coverings, the two 
sacs form the labia majora. The pudendal sac contains more or less 
fatty tissue, and the terminal fibers of the round ligament of the uterus are 
also lost in it. The sac may be the seat of hydrocele from a patulous canal 
of Nuck, or a hernia may develop by a descent of a section of gut or omen- 
tum through this canal. The injection of air into the sac gives a similar 
appearance to that induced by hernia. The fascia passes around the 
transverse perineal muscles to form the anterior layer of the triangular 
ligament. This union forms the ischioperineal ligament — a very firm 
aponeurotic band attached to the outer ends of the rami of the ischii in 
front of their tuberosities. 

c. The deep fascia, or triangular ligament, has two layers: an anterior, 
or superficial; and a posterior, or deep. The superficial is attached to the 
rami of the pubes and ischium, and to the so-called transverse ligament of 
the pelvis, which lies immediately behind the subpubic ligament, from 
which it is separated by an opening for the dorsal vein of the clitoris. 

This superficial layer is united posteriorly with the superficial, as well 
as with the deep layer of the pelvic fascia. The deep layer is likewise 
attached to the rami of the pubes and ischium, and joins the obturator 
fascia covering the lower portion of the anterior surface of the levator ani 
muscle. In front it is continuous with the vesicorectal fascia; behind, 
with the dense anal fascia which covers the under surface of the levator ani 
muscle. 

The junction of the three layers of fascia forms the ischioperineal 
ligament, which marks the boundary-line between the urogenital and the 
anal regions. 

The upper surface of the levator ani muscle is covered by a fascia called 
the pelvic, which is a continuation of the iliac. The pelvic fascia is at- 
tached to the iliac portion of the iliopectineal line and to an oblique line 
upon the posterior surface of the pubic bone, from above and within the 
obturator foramen, to just below the symphysis. It covers the inner sur- 
faces of the ilium and ischium about halfway down the pelvic wall, until 
it reaches the so-called tendinous arch, which extends from the spine of 
the ischium to the pubic bone and below the obturator canal. This por- 
tion covers the obturator muscle, and is known as the obturator fascia. 
A thinner prolongation extends backward, and is known as the pyriform 
fascia. 



12 



GYNECOLOGY. 



The pelvic fascia splits into two layers at the tendinous arch: an upper, 
called the vesicorectal fascia, which extends over the levator ani muscle, 
and a lower layer, which follows the obturator internus muscle to the inner 
edge of the ischiopubic branches, and retains the name of obturator fascia. 
Below the insertion of the levator ani muscle is given off an investment, 
which is called the anal fascia. In conjunction with the portion of ob- 
turator fascia below the tendinous arch it serves as a lining for the ischio- 
rectal fossa. 

The vesicorectal fascia, from its insertion upon the pelvic wall, passes 
inward and downward and covers the upper surface of the levator ani to 
the base of the bladder, the vagina, and the rectum. In front, near the 
middle line, a thicker part of this fascia forms the anterior true ligaments of 
the bladder, or pubovesical ligaments. 

A ligament of the rectum arises from the ischial spine and is attached to 
the side of the rectum. It presents a double layer of fascia with the inter- 
vening loose connective tissue, and permits a sliding movement of one part 
over another. 

A study of the relations of the pelvic structures to the layers of the 
fascia results in the following, according to Hart and Barbour: 



Between the skin and superficial fascia; 



Between the deep layer of the super- 
ficial fascia and the anterior layer of 
the triangular ligament: 



Between the layers of the triangular 
ligament: 



Superficial hemorrhoidal vessels and 

nerves. 
Superficial perineal artery and nerve. 
Transversus perinei. 
Bulbocavernosus. 
Erector clitoridis. 
Transverse perineal blood-vessels and 

nerves. 
Venus plexuses. 
Bulbs of the vagina. 
Pudendal sacs. 

Dorsal artery and vein of clitoris. 
Compressor urethrae. 
Vagina, in part. 
Urethra, in part. 
Pudic vessels and nerves. 



5. Pelvic Diaphragm. The structures already described as the soft 
parts, consisting of the pelvic fascia and the muscular structures, con- 
stitute the pelvic diaphragm, of which the most important structure is the 
levator ani. (Fig. 16.) 

The origin and insertion of this muscle have been given. It is gen- 
erally described as two muscles, the levator ani and the coccygeus, but as 
there is practically no separation, this seems an unnecessary distinction. 
Savage divides it into three, the pubococcygeus, the obturator coccygeus, 
and the ischiococcygeus, but this division seems inappropriate when we 
recognize the fact that none of the muscular fibers arising from the pubes 
reach the coccyx. The anterior portion of the muscle is covered by 
the muscles and structures of the external genitalia. The posterior 
portion is enveloped with the fascia and covered with the following 
additional layers: the skin; the adipose tissue filling up the ischio- 



EMBRYOLOGY. 



13 



rectal fossa, and known as the ischiorectal fat. The boundaries of this 
irregular triangular space are the levator ani, covered by the anal fascia 
on the inner side, and the obturator internus muscle, covered by the ob- 
turator fascia on the outer side. The lower surface is bounded by the 
anterior edge of the gluteus maximus muscle and the greater sacrosciatic 
ligament behind, the transversus perinaei muscle in front, and the sphincter 
ani upon the inner side. The apex of the triangle is at the spine of the 
ischium. Behind, the two fossa communicate by the loose adipose tissue 
back of the rectum, and also by the pelvic fascia. In front, the fossa is 
limited by the line of junction of the superficial and the deep fasciae. 




Fig. 16. — The Under Surface of the Levator Ani Muscle. {Deaver.) 



The posterior fibers of the levator ani pass behind the rectum and are 
continuous with those of the opposite side. Other fibers are attached to 
the tip and side of the coccyx. 

The action of the pelvic diaphragm is to strengthen the pelvic floor, 
and, in association with its two enveloping layers of fascia it forms a strong 
support for the uterus and bladder. Observation of the movements of the 
floor, with the employment of Sims' speculum, reveals a rhythmic move- 
ment synchronous with respiration. The anterior pelvic segment goes 
downward and backward during inspiration and upward and forward 
with expiration. The muscle serves to raise up the rectum during def- 



H 



GYNECOLOGY. 



ecation and draws the anus toward the symphysis. The fibers between 
the rectum and vagina influence the size of the vaginal -orifice. 

6. Perforations (Fig. 17). The pelvic floor is perforated by three 
slit-like openings, two of which, the vagina and urethra, have axes parallel 
with the conjugate diameter of the brim. The rectum for a part of its 
course is similar, but turns backward at the lower part, where it is sepa- 
rated from the vagina by the perineal body. The axis of the anus is at 
right angles with the plane of the brim. Transverse section of the pelvis 
through the middle and lower third of the vagina shows it folded in the 
shape of a letter H, with a short lateral and a long transverse bar. The 
urethra presents a transverse sHt, and the rectum an anteroposterior fold. 




Fig. 17. — The Upper Surface of The Levator Ani Muscle. {Deaver. 



7. Internal Genitalia. The internal genitalia are: The vagina, 
the uterus, the Fallopian tubes, the ovaries, and the parovarium. 

The vagina is a musculomembranous canal, lying between the bladder 
and rectum, and extending from the vulva to the uterus. It is fixed below 
by its attachments to the pelvic floor, and above surrounds the cervix, with 
which it is continuous. The direction of the vagina varies with the po- 
sition and the condition of the adjoining organs — the bladder and the rec- 
tum. In the erect position it forms an angle of about 60 degress with the 
horizon, and is parallel with the conjugate diameter of the brim of the pel- 
vis. (Fig. 18.) Its walls are irregularly triangular, with the widest point 
at the upper part, where the uterus enters, which in the nullipara measures 
3 or 4 cm. ; in multiparae, 6 or 7 cm. The anterior wall is the shorter, 5 
cm. long, while the posterior is 7.5 cm. In the normal condition and with 
the bladder empty, the cervix enters the vagina at a right angle. This 



EMBRYOLOGY. 



15 



angle is rendered more obtuse by distention of the bladder or by an ac- 
cumulation of feces within the rectum. The vagina is attached to the 
cervix about 1.5 cm. from the external os, and forms with the cervix a sul- 
cus front and back. The former is known as the anterior, and the latter 
as the posterior, vaginal fornix. The anterior and posterior vaginal walls 




Fig. 18. — A Mesial Section; the Body Erect. (Deaver). 

lie in contact, and, upon mesial section, present a slit with a slightly con- 
vex line directed anteriorly. Transverse section is represented by an H- 
shaped slit, the lateral arms of which are convex upon their inner aspect, 
with the horizontal limb being slightly anterior. 

The vagina in multiparas is capable of wide distention and varies in 



i6 



GYNECOLOGY. 



shape. The anterior vaginal wall is united with the posterior surface of 
the bladder by loose connective tissue which permits its dissection, though 
separation rarely occurs. The urethra is more intimately associated with 
this wall. However, it presents no difficulty in dissection. 




The mucous membrane of the anterior wall is thrown into numerous 
folds or projections, called the rugae, which are more marked toward the 
vulva and decreases in size as the upper end of the canal is approached. 
There are also temporary foldings, which disappear as the vagina is dis- 



EMBRYOLOGY. 1 7 

tended. The rugae consist of a series of transverse ridges, which extend 
obliquely upward and outward from the longitudinal stem, known as the 
anterior column. 

The transverse projections are composed of secondary ridges, covered 
with papillae. The anterior column generally begins behind the meatus, 
and disappears in the upper third of the vagina; occasionally, its lower 
portion is divided into two parts by a longitudinal groove, the opposite 
halves of which subsequently unite. The rugae are especially marked in 




Fig. 20. — Arteries and Nerves of the Female Perineum. (Savage.) 
I. Internal pudic. 2, 3. Inferior hemorrhoidal, 4. Transverse perineal. 5. Superficial 
perineal or vulvar. 7. Profunda branch to the clitoris. 8. Artery of the bulb. 9. Dor- 
sal artery to the clitoris. 10. Inferior hemorrhoidal nerve to sphincter and lower rectum. 
II. Posterior superficial. 12. Posterior muscular. 13. Trunk of the nerve 14. 
Anterior superficial branches to the vulva. 15. Anastomotic. 16. Pudendal branch 
of (17) the smaller sciatic. 18, 18. Continuation of pudic ending in nervous sheath for the 
clitoris, ig. Outer terminal branch of the iUo-inguinal nerve. A. Anus. M. Urinary 
meatus. C. Clitoris. L. Greater sacrosciatic ligament. V. Vagina. O. Coccyx, a. 
Gluteus maximus. b. Superficial sphincter. c. Anterior edge of ischiococcygeus. d. 
Superficial transverse muscle, e. Bulbocavernosus muscle. /. Slip of anterior aponeu- 
rosis of perineal septum, h. Upper portion of erector clitoridis muscle, j. Adductor 
magnus. k. Gracilis muscle. T. Nerve-fibrils to integument. 

young children and virgins, and largely disappear in the multipara. The 
posterior wall also presents a column with transverse rugas, but less marked 
than upon the anterior. 

The upper part of the vagina presents, when distended, a dome-like 
appearance, in which the posterior fornix is twice the depth of the anterior, 
owing to the higher attachment upon the cervix. The lateral fornices 
have no especial depth, and only connect the anterior and posterior. 
As the patient advances in years the vaginal walls atrophy and the 
rugag gradually disappear. 



i8 



GYNECOLOGY. 



The wall of the vagina consists of three layers : an external connective- 
tissue layer; a middle, of unstriped muscular fiber; and an inner, of mu- 
cous membrane. The exterior layer binds the uterus to the surrounding 
structures and supports the plexus of vessels and lymphatics. The 
muscle structure consists of longitudinal and circular fibers, intricately 
interlaced. 

Luschka describes a bundle of striated muscle-fibres, which he calls 
the sphincter vaginae, surrounding the lower end of the vagina as well as 

the urethral orifice. The mucous membrane, 
which extends from the free edge of the hymen 
to the cervix, over which it is reflected to the 
external os, varies in thickness from i to i 
1/2 mm. It is of a rosy-red color, but may 
vary from a light pink to a dark-purple 
or slate color. The latter color is especi- 
ally characteristic of pregnancy. The mucous 
membrane is closely attached to the subja- 
cent muscular layer, and is thrown into the 
already mentioned rugae. The surface is 
covered with numerous papillae, which are 
greatly increased in size by pregnancy. 

The mucous surfaces are covered with an 
acid mucus, which is also markedly increased 
during pregnancy. 

The thickness of the vaginal wall is greater 
below, where it is about i cm., while at the 
upper part it is not over 5 mm. The differ- 
ence in thickness is due to the variation in 
the muscular wall. 

A microscopic section of the vaginal wall 
presents an external layer of fibrous tissue, 
enveloping large veins, which belong to the 
vaginal venous plexus. These are surrounded 
by bundles of smooth muscle-fibers suggestive 
of erectile structure. Accompanying the veins 
are large lymphatics, some of which are 
distended to form sinuses. A middle or mus- 
cular layer is also present, in which the outer 
fibers seem divided transversely, the inner ones 
being longitudinal. 

The mucous membrane consists of a firm basement membrane in 
which are numerous elastic fibers. It is covered by several layers of 
stratified pavement epithelium. (Fig. 22.) In addition to the large 
folds into which the mucosa is thrown, it forms secondary elevations, 
or papillae, in each of which is a capillary loop. These loops are single 
near the fornix, but present a more complicated network near the introitus. 
The rugae consist of large venous plexuses surrounded by bundles 
of muscle-fibers, as in cavernous tissue. 




u 

Fig. 21. — Anterior Wall of 
Vagina, Showing Columnse 
Rugarum. 

{By ford, after Savage.) 

I, 2. Anterior columns of 
the vagina. U. Urethral orifice. 
M. Cervix. 



EMBRYOLOGY. 



19 



The lymphatics are abundantly supplied to the mucosa. Lauen- 
stein has described lymph-follicles similar to those in the intestine. 

The existence of mucous follicles or glands in the vagina is denied; 
the mucus is believed to be an exudation from the vaginal surface. 

The nerves ramify throughout the walls, communicate with one 
another and with the ganglia, and terminate in endbulbs beneath the 
epithelium. 

The uterus, or womb, is a hollow, thick-walled, muscular organ, of 



ff^T??-^!!!; 



'V'lii'/lK'V: 



v/ 






'i;d^ 



m.. ' :^^mik m^^^^ 'W.thwj] 









i^;^PM' 



•(( 







Fig. 22. — Horizontal Section of the Vagina and Urethra of an infant, 
o, a. Skene's glands, b, b, b, b. Urethral glands; the analogue of Littre's glands in the male. 

a truncated shape, which occupies the upper part of the cavity of the 
pelvis and projects by a portion of its lower end, the cervix, into the 
vagina. It is situated between the bladder in front and the rectum behind. 
The upper end, the fundus, is usually just below the level of the 
plane of the brim of the pelvis and about 2 cm. in front of the sacrum. 
The position of the uterus is dependent upon the condition of the sur- 
rounding organs. When the bladder is empty and the rectum undis- 
tended, the uterus is slightly anteflexed, and occupies a position at a 



20 



GYNECOLOGY. 



right angle to the axis of the vagina. The fundus is directed forward 
and upward, and the cervix downward and backward, toward the rectum. 
A distended bladder raises the fundus and decreases the uterovaginal 
angle. A similar change of position is induced by rectal accumulations 
which push the cervix forward. Necessarily, therefore, it is difficult 
to determine between a physiologic and a pathologic position. We 
may call any position abnormal in which the organ becomes fixed and 
the range of mobility lessened. The uterus presents from above a pear- 
shaped appearance. It is slightly flattened from before backward with 
its posterior surface convex. 




Fig. 23. — Median Section of Uterus from Side to Side through the Fallopian 
Tubes. Mode of Junction of Vagina and Uterus. (Savage.) 
a. Uterine cavity, b. Cervical canal, showing folding of its mucous membrane, d. Internal 
uterine (mucous) coat. c. Os externum uteri, e. Uterine aperture to Fallopian tube. 
f. Fallopian tube near uterus, g. Round ligament. V. Vagina. 



The length of the virgin uterus is from 5 to 7.5 cm.; its breadth at 
the orifices of the Fallopian tubes, 5 cm. ; and its walls are about i cm. 
thick. The weight of the nonimpregnated uterus is from about 300 grains 
to I 1/2 ounces. The organ is divided into two portions — the body and 
the cervix. The body, pyriform in shape, about 4 cm. long, is surmounted 
above a line drawn through the orifices of the Fallopian tubes, by a round- 
ed portion — the fundus. The cervix, cylindric in form, is about 3 cm. 
long and terminates below in the vaginal portion. Schroder divides the 
cervix into three parts: the upper and lower, called the supravaginal 



EMBRYOLOGY. 21 

and infravaginal portions, which are separated by an intermediate por- 
tion — a division which is of significance in the study of uterine displace- 
ments. 

The attachment of the vagina to the uterus is much higher behind. 
When the patient occupies the dorsal position, with the limbs well drawn 
up, the vagino-uterine junction is upon a plane vertical to the horizon. 
The infravaginal portion of the cervix is especially interesting to the 
gynecologist, as it is the only part of the uterus which is visible upon 
inspection, and fully accessible to palpation. It varies extremely in size 
and shape, according to the age and sexual relations of the individual. 
In the virgin it presents a conoid projection, nearly i cm. long, with an 
opening in its apex, known as the external os, or os tincae. The os is a 
transverse slit, about two or three millimeters long, and it divides the 
cervix into an anterior and a posterior lip. The anterior lip is the longer. 

With the advent of sexual activity the cervix changes. In the nulli- 
parous married woman it becomes softer and larger, the conoid shape 
is less marked, and the os stands more widely open. In the multipara, 
even when lacerations havx not occurred, the cervix is large and soft, 
and the os presents a transverse slit — more frequently an irregular 
opening. Inflammatory lesions cause the cervix to become still larger, 
with eversion of the mucous membrane, erosion of the surface, enlarge- 
ment of the papillae, and an irregular opening. 

With the cessation of menstruation, and especially in women who have 
borne a large number of children, the vaginal cervix disappears and the 
OS is flush with the fornix of the vagina. 

The junction of the triangular body and conoid cervix is called the 
isthmus. The anterior surface is flattened; the posterior, quite convex. 
The upper border of the uterus is rounded, and forms the fundus. The 
lateral uterine borders are obscured by the folds of the peritoneum, 
known as the broad ligaments. The upper part of each ligament is 
occupied by the Fallopian tube; below this, the round ligaments; and 
still lower, the ovarian ligament. 

The arteries, veins, and lymphatics of the pelvis pass through the 
broad ligament. 

The uterine canal in the virgin (Fig. 24) is about 5 cm. long; slightly 
longer in the multipara. The cavity of the cervix is cylindric, wider 
in the center and narrower at each end, with the external os below and 
the internal os above. 

The cavity of the body is triangular from side to side, but the anterior 
and posterior surfaces lie in contact. At the apex of each angle of the 
triangle is found an opening, on each side the orifices of the Fallopian 
tubes, and below the internal os. 

The uterine wall has a thickness of a little more than i cm. The 
uterus has three layers — an external (serous), a median (muscular), and 
an internal (mucous membrane). The serous or peritoneal covering is 
not complete, and, therefore, wfll be considered with the peritoneum. 

The muscle-fibers are best studied in the pregnant uterus, and may 
be divided into three layers. The external is most distinct, and consists 



22 



GYNECOLOGY. 



of a fine, thin layer over the anterior and posterior surfaces, from which 
prolongations are sent off into the broad ligament. The posterior fibers 
form the ovarian ligament, and the anterior the round ligament. Some 
of the fibers also furnish the longitudinal muscular structure of the 
Fallopian tube. These fibers are wanting upon the sides of the uterus. 
The middle layer is by far the thickest, and consists of interlacing fibers, 
transverse and longitudinal, which are continuous with those of the 
vagina. This layer comprises the principal part of the wall, and contains 
the blood-vessels. The latter 
are embedded in a network 
of fibers, and are visible to 
the naked eye upon cross- .^1; S^^ 





Fig. 24. — ^Virgin Uterus, Median Section. 
Byford after Sappey. 

I. Anterior surface. 2. Vesico - uterine 
pouch. 3, 3, 4, 5, 6, Posterior sur- 
face. 7. Cavity of corpus. 8. Cav- 
ity of cervix. 9. Os internum. 10, 

11. Vaginal portion of cervix. 12, 

12. Vagina. 



Fig. 25. — Mucous Membrane of Uterine 
Body showing FoUicles. Mann. 

d, d, d. Simple or double culdesac of these 
folHcles. a, a, a. Thin cup-shaped 
orifice upon the mucous membrane. 



section. Their intimate relation to the muscle and tissue is recognized 
by their remaining open when divided transversely. 

The inner layer consists of circular fibers, which are most marked 
at the internal and external os, where they form a sort of sphincter, and 
at the cornu of the uterus, from which they are extended into the Fallopian 
tubes. 

The connective tissue of the uterus is thickly interspersed'between the 
muscle-fibers, and especially along the course of the vessels. The mucous 
membrane of the uterine cavity rests directly upon the muscle layer with- 
out any intervening submucosa, and its glandular structure projects 
between the muscle-fibers. In the cervical cavity, where the mucosa is 
thrown into folds, a distinct areolar layer intervenes between it and the 
muscular wall. The uterine mucosa is one millimeter in thickness at the 



EMBRYOLOGY. 



23 



fundus, but becomes thicker near the center of the cavity. It is smooth 
and velvety, of a grayish-red color, and presents no folds, unless in the 
immediate vicinity of the tubal opening, and there but a slight folding. 
Under a glass can be seen numerous small depressions or openings — the 
orifices of the glands. The free surface of the mucosa is covered with 
a single layer of columnar epithelial cells,which are supplied with cilia. 








?-"^.' 







Fig. 26. — Section of Normal Endometrium. Note two glands to right some- 
what enlarged. 
a, a. Glands penetrating muscular substance. 

The mucosa is filled with glands of the tubular variety, which penetrate 
its entire thickness, and frequently their external extremities are embedded 
in the muscular layer. (See Fig. 25.) The direction of these tubules 
is more or less oblique. They often exist as sinuous or spiral single tubes, 
but more frequently divide into two or more branches near their lower 
ends. Upon longitudinal section they exhibit a basement membrane 
lined by a single layer of prismatic ciliated cells with single layer nuclei 
situated near their bases. (See Fig. 26.) There glands largely increase 
with the approach of puberty, and become elongated during menstruation, 



24 



GYNECOLOGY. 



especially in pregnancy. The mucosa is supplied with large plexuses 
of capillaries and lymphatics. The latter, in the forms of lymph-spaces, 
are directly connected with the lymph-sinuses and vessels of the deeper 
layer. The termination of the nerve-filaments in the mucosa has not been 
determined, but the action of the glands indicates their reception of 
nerve-filaments, as in similar structures of other parts of the body. 

The cervical mucosa, thicker than that of the body, is thrown into 
several folds, known as the arbor vitae, or plicae palmatae, and is separated 
by a submucosa from the muscular wall. This arrangement of the 
mucosa ends sharply at the internal os, and is best observed in the 
virgin cervix. The mucosa differs from the lymphoid structure of the 

body in having a firm, fibrous 
basement membrane, surmounted 
by cylindric epithelial cells. These 
cells, according to De Sinety, are 
ciliated only upon the summit of 
the ridges, while the epithelium 
covering the intervening surfaces is 
nonciliated. The glands are of the 
racemose variety, consisting of 
branching ducts. They are lined 
with nonciliated cuboid epithelium, 
resting upon a structureless base- 
ment membrane. They open on 
the free surface, upon and between 
the folds, and secrete a clear, viscid, 
alkaline mucus. The ovula Nabothi 
are those glands of Naboth which 
have formed small cysts after occlu- 
sion of their ducts. 

The structure of the cervical 
wall differs from that of the body in the increase of fibrous tissue, which 
is intimately interwoven with the muscle fiber, and in the lessened supply 
of blood-vessels. 

The external os presents a sharp line of demarcation separating the 
one-layered cylinder epithelium of the cavity from the multiple-layered 
pavement epithelium of the vaginal portion. 

The Fallopian tubes, or oviducts, are two tortuous canals which 
arise from each side of the fundus uteri. They vary in size and length, 
occupy the upper margin of the broad ligament, and extend outward 
almost to the pelvic brim. The length of the tube is from 7.5 cm. to 
12.5 cm., the right tube usually being the longer. 

They are first directed outward, then backward, and finally inward, 
giving the appearance of a shepherd's crook. The tube presents for our 
study: i, in the uterine cavity a narrow, funnel-like opening, the ostium 
uterini tubcB; 2, the section of the canal found in the uterus, pars uterini; 3, 
the narrow portion proximal to the uterus, the isthmus tubce; 4, a wider, 
longer, more tortuous portion, the ampulla tubce, which terminates in 




Fig. 27. — Virgin Os and Cervix. (Sappey.) 



EMBRYOLOGY. 25 

5, a distinct trumpet- shaped end, the infundibular tubes, provided with 
numerous fimbriae; and 6, a distinct opening from the ampulla, the 
ostium abdominale tubcE. The line of differentiation between the pars 
uterini, isthmus, and ampulla is not sharply defined. The isthmus is 
the narrowest portion and is about two centimeters long. The diam- 
eter of the isthmus is about two millimeters, and its lumen will scarcely 
admit a bristle. The ampulla is the more widened part. It extends out- 
ward and backward, has an external diameter of six to eight millimeters, 
and its lumen a diameter of two or three millimeters. 



Fig. 28. — Section of Fallopian Tube through the Isthmus. 
a, a. Shows the firm and compact structure of the longitudinal folds in this portion of the tube. 

The fimbriated extremity — also called the pavillion, or infundibulum, 
from its funnel shape, and the morsusdiaboli (devil's mouth) — is a trumpet- 
shaped opening, surrounded by primary and secondary fimbriae resemb- 
ling the tentacles of the sea anemone. The primary fimbriae are the larger 
processes, four or five in number, from which arise the eight or ten secon- 
dary processes. 

The longest fimbria (fimbria ovarica) anchors the tube to the ovary 
and has a furrowed groove, which facilitates the passage of the ovum to 
the tubal orifice. The broad ligament is continued to the lateral wall 
of the pelvis by a small fibrous band, known as the infundibulopelvic 
ligament. 

The tube, upon repeated section, will be found to have varying 
dimensions, and frequently its course is tortuous — almost convoluted. 
It has two openings: the uterine and the abdominal. The latter is more 
distensible than the remaining portion of the tube, is somewhat trumpet- 
shaped, and affords a communication with the peritoneal cavity. 

The tube consists of four coats or layers: the external, serous cover- 
ing which is separated from the muscular layer by a subserous coat, the 



26 GYNECOLOGY. 

tunica adventitia; next a muscular; and lastly the internal — the mucous 
membrane. 

The external serous covering is incomplete, that portion of the tube 
toward the broad ligament being incomplete for the inner two-thirds 
of the tube. The remaining third is surrounded by the peritoneum, 
which covers the external surface of the fimbriae, while the internal is 
lined by the mucosa. The tunica adventitia envelops the muscular layer, 
allowing the peritoneal to slip over its abdominal end. The muscular 
coat consists of longitudinal and circular fibers. The former is con- 
tinuous with the outer; the latter, however, is predominant and a continua- 
tion of the inner muscular layer of the uterus. The muscular structure is 
more largely developed at the proximal than at the distal end of the tube, 
and the circular fibers are particularly well marked at the isthmus, 
where they form what is called the sphincter tubae. The tubal mucosa 
is quite thick, thrown into longitudinal folds, very vascular, and of a 
bright red color. In the isthmus the mucosa presents simple folds, which 
become more complex in the ampulla. Hennig has counted from three 
to five primary folds, which have between eight and ten smaller plicae 
between each pair of the former. The secondary folds are less marked 
near the abdominal extremity, where the longitudinal folding is apparent 
to the naked eye. 

The mucosa has a single layer of ciliated columnar epithelium upon 
two or three layers of supporting cells, which are round or pyriform. 
The cells terminate abruptly at the ends of the fimbriae, where the margin 
between the columnar and pavement epithelium is marked distinctly. 
The tubal mucosa, like the uterine, has no distinct submucous layer but, 
unlike the latter, it is without glands, and is covered with a thin layer 
of grayish mucus of a distinctly alkaline reaction. 

The ovaries, the germ-bearing organs of the woman, are a pair of small 
bodies analogous to the male testicle. One is situated on the posterior 
surface of each broad ligament, below the tube and at each side of the 
uterus. 

The ovaries occupy a position at the level of the brim of the pelvis, 
or partly below and partly above its plane. 

The axes of the ovaries lie obliquely to the pelvis, with a slight incli- 
nation forward. In the erect position they rest upon the posterior surface 
of the broad ligament. 

The Fallopian tube is situated in the broad ligament above and partly 
encircling the ovary, while the round ligament is in front and occupies 
its anterior fold. In front, between the ovary and the tube, is the par- 
ovarian structure or the organ of Rosenmiiller. The inner or uterine ex- 
tremity of the ovary is connected with the uterus by some muscle fibers, 
about three centimeters long, known as the ovarian ligament; the outer 
or tubal extremity is connected above with the end of the tube through the 
fimbriae ovarica, and below with the infundibulopelvic ligament. 

The ovary presents a flattened, avoid appearance, with its broad end 
directed externally and the pointed end toward the uterus. The ante- 
rior straight, or flattened, surface of the ovary is fixed by a short serous 



EMBRYOLOGY. 



27 



duplication, the mesovarium, to the posterior surface of the broad 
ligament. The posterior convex margin is free. Its size varies with 
the age of the individual, the functional activity of the organ, and the 
occurrence of menstruation or pregnancy. The ovary attains its greatest 
size about six weeks after parturition (Hennig), and never returns to 
its former size in the subsequent involution. 

Following the menopause, it shrinks to one-half or one-third of its 
dimensions during active sexual life. Luschka gives as its dimensions: 
length, 4 cm.; width, 2.2 cm.; thickness, 1.3 cm. It weighs from 60 to 
135 grains. 




Fig. 29. — Section of the Fallopian Tube through the Ampulla near the Isthmus, Sho\\-ing 
Extensive Folding of the Mucous Membrane. 

The color of the ovary is a pinkish-gray, becoming somewhat dark- 
ened as menstruation approaches. Immediately after ovulation a dark 
swelling follows, due to the accumulation of blood. As absorption pro- 
gresses the color changes and the mass becomes yellow, and later presents 
only a whitish cicatrix. Before puberty the ovary is smooth, but subse- 
quently it becomes irregular, from the cicatrices following repeated rup- 
ture of cysts, or nodular, from the presence of matured follicles that have 
failed to rupture. Following the menopause, the ovary becomes a pearly- 
white, irregular, almost cartilaginous mass, about one-half or one-third 
its former size. 

The ovary is situated upon the posterior surface of the broad ligament, 
with its pointed end connected with the uterus by the ovarian ligament. 
The ovary, by its pointed end, is directed toward the ligament, and its 
stroma extends inward upon the latter, while the external ovarian end 
is blunt and large. The posterior surface of the ovary projects through 



28 



GYNECOLOGY. 



the peritoneum and is uncovered by it. The union of the columnar 
epithelium of the ovarian surface with the pavement epithelium is readily 
recognized as a white line, and is called the white line of Farre. 

Sections of the healthy ovary show two kinds of tissue; a central or 
medullary, and a cortical or peripheral portion. The latter covers the 
entire surface of the ovary bounded by the line of Farre, but projects to 
its greatest depth (two to three millimeters) at the central portion of the 
convex surface. The central structure has a pinkish-gray or rosy color, 
is of soft consistence, and has a moist, glistening appearance. It is of a 




Fig. 30. — Section of Ovary, Showing Graafian Follicles. (Wyder.) 



white or grayish-white color, more or less firm in consistency, and contains 
numerous small vesicles. The smaller vesicles are situated near the 
surface, while larger cysts are situated deeper. Some of these reach the 
size of a pea, and may project more or less beyond the free surface. The 
sac-wall is frequently so thin that the vesicles rupture under the slightest 
pressure. This layer also contains numerous depressions or scars, the 
result of repeated ovulation. 

The cortical layer of the ovary, or that part which projects through 
the peritoneum, is covered by a single layer of short, columnar epithelium, 
called by Waldeyer the germinal epithelium. This undergoes a transition 



EMBRYOLOGY. 29 

at the white line to the pavement epithelium of the peritoneum. Before 
puberty young ova are represented by large spheroid cells, with marked 
nuclei, which form in the columnar cells. Ingrowths of the germ epithe- 
lium into the underlying stroma are occasionally seen, which form the 
ovarial tubes of Pfiliger. 

Immediately beneath the epithelial layer, and quite inseparable from 
the underlying stroma, is the tunica albuginea. This is a thin, dense 
layer of fibrous tissue, which contains a few smooth muscles-hbers. 
It is not completely developed until the third year, and undergoes changes 
with age and inflammation until it becomes thickened and of almost 
cartilaginous hardness, which renders its rupture exceedingly difficult. 
Such alterations from inflammatory changes are a cause of the formation 
of retention cysts, and of the development of that condition known as 
cystic disease of the ovaries. The structure of the ovary, as already 
noted, is divided into a cortical and a medullary portion, although they 
differ but little in structure except that the latter is softer and more vascu- 
lar. In the cortical layer lie the Graafian follicles, embedded in connec- 
tive tissue interspersed with some muscle-fibers. A large number of these 
follicles, variously estimated at from 36, 000 to 400,000, are found in each 
ovary. Whether so large a number exists is difficult to determine, but 
it remains e\ident that nature has amply provided for the reproductive 
function. 

The ovarian stroma is the framework or bed in which the follicles 
rest and are nourished. Each Graafian follicle has a w^all, which con- 
sists of a tunica fibrosa of thin fibrous tissue, within which is a more 
delicate membrane, called the tunica propria; the latter contains many 
granular cells and a fine network of capillary vessels. This tunica propria 
is lined with several layers of epithelial cells, called the membrana granu- 
losa, separated from the tunica propria by a structureless membrane. 
These epithelial cells form a thickened mass upon one side, which projects 
into the cavity — the discus proligerus. The cavity of the follicle is filled 
with a clear, serous fluid, called the liquor foUiculi. It is formed by 
liquefaction of the cells of the membrana granulosa. 

The Graafian follicle, when mature, is one millimeter in diameter. 
•Embedded in the discus proligerus is found the ovum, which has been 
called the typical cell; it measures from 0.2 to 0.3 mm. It is a yellow, 
spheroid body, enveloped by a thin, delicate membrane — the vitelline 
membrane, or zona pellucida — doubtless formed from the innermost cells 
of the discus proligerus. Within this membrane is contained the vitellus, 
a network of granular, fibrillated protoplasm containing numerous fat- 
globules. In the outer portion of this network is a light spot, which con- 
sists of fine, fibrillated protoplasm, which contains in its meshes a granular 
material inclosed in a distinct membrane. This structure is known as the 
nucleus, or germinal vesicle. Within this is contained a small, highly 
refracting, granular body, known as the nucleolus, or germinal spot. 

The Graafian follicle is surrounded by a vascular network; as it 
matures, the liquor folliculi increases, the cyst becomes tense, approaches 
the surface, and the tunica albuginea becomes thinned and finally rup- 



30 



GYNECOLOGY. 



tures, permitting the ovum to escape. The cavity of the follicle fills 
with blood, which coagulates and forms a clot. Later, this clot presents 
an external yellowish color, while its center is of a reddish-gray hue. 
The clot gradually becomes organized, contracts (by which it is thrown 
into folds), and is gradually absorbed. The clot thus formed is known 
as the corpus luteum. The ovary of a normally menstruating woman 

will be found to contain a 
number of corpora lutea in 
various stages of retrogression. 
The structure generally dis- 
appears by the end of the 
twelfth week, excepting a small 
cicatrix, the corpus albicans, 
which remains. 

When pregnancy occurs, 
the corpora lutea do not con- 
tinue to form, but the one cor- 
responding to the last mens- 
truation becomes much larger 
and remains longer. It con- 
tinues to increase, and after 
the first month forms a large 
yellow clot, which gradually 
becomes decolorized and more 
highly organized, resulting in 
a white, fibrinous clot sur- 
rounded by a yellow ring. 
The corpus luteum of preg- 
nancy is known as the corpus 
luteum verum, while those 
which occur with ordinary 
ovulation are called corpora 
lutea spuria. 

Later in the pregnancy, 
the time of which is not ex-- 
actly known, it becomes con- 
tracted, and at its termination 
forms a mass about 0.5 cm. in 
diameter. 

When the corpus luteum 
has lost its color, most of its blood-vessels, and is mainly composed of 
a mass of fibrous tissue, it is called a corpus albicans. Frequently, from 
the retention of pigment, it is dark in color, and is known as a corpus 
nigricans. Clark has shown that the corpus luteum finally disappears 
by the process of hyaline degeneration. Extravasations of blood, or 
apoplexy of the ovary, as we shall see later, are not infrequent, and occa- 
sionally may result in the complete destruction of the organ and the 
formation of a blood-sac — an ovarian hematoma. 




Fig. 31. — Large Corpus Luteum in Association 
with an Ovarian Dermoid. Removed from an 
Unmarried Woman Who Had Never Been Preg- 
nant. (Sutton). 

I. Twisted pedicle. 2. Corpus luteum. 3. Old 
clot. 4. Integumentary surface of dermoid. 



EMBRYOLOGY. 3 1 

The Parovarium. Between the external end of the tube and the ovary 
is situated a triangular group of small tubules, known as the parovarium, 
or the organ of Rosenmiiller — a remnant of the Wolffian body. The 
structure corresponds to the epididymis in the male. 

The apex of the triangle is directed toward the ovary. This organ 
is of especial importance to the gynecologist, as it can be the seat of a 
number of growths. It consists of six to thirty spiral tubules, which at 
their base open into a single transverse tube. This transverse tubule 
corresponds to the canal of Gartner in the lower animal. Cysts are 
frequently found associated with the tubules; the most common is the 
hydatid of Morgagni, or appendix vesiculosa, the pedicle of which arises 
in a point of the mesosalpinx, near the fimbria ovarica. The occurrence 
of this cyst is the rule rather than the exception, and it consists of a tough, 
connective-tissue wall with a well-developed vascular system, and is 
lined with pavement epithelium. It has a pedicle one-third centimeter 
long and contains clear fluid. The parovarium is entirely a rudimentary 
structure and has no function. 

Urinary Organs and Rectum. Our knowledge of the relations of 
the pehdc organs will be incomplete without a study of the analogy of 
the urethra, bladder, and ureters, as well as of the rectum and anus. 

The urethra is a canal, from 2.5 cm. to 4 cm. long, which forms the 
outlet to the bladder. It lies embedded in the anterior vaginal wall, 
from which it can readily be separated. It is slightly curved upward, 
with its concavity forward. Upon cross-section the urethra presents 
a transverse slit near its vesical end and a stellate folding toward the 
external meatus. The diameter of the urethra is 0.6 cm., and it is quite 
distensible. When not distended, the urethral mucous membrane is 
more or less corrugated throughout its length, owing to the sphincter- 
like action of the surrounding muscle-fibers. The urethra is attached 
to the pubic arch by the pubovesical ligament, and penetrates the triangu- 
lar ligament, between the layers of which it is surrounded by the fibers of 
the compressor urethrae, or muscle of Guthrie. 

It is also, together with the vagina, influenced at its lower end by the 
bulbocavernosus muscle. Its external opening is known as the external 
meatus, and close inspection of its orifice will reveal a number of small 
openings about it — the orifices of the glandulae vestibulares minores. 
Within the meatus are two small openings — the orifices of the tubules, 
described by Skene. They correspond to the lacuna magna in the fossa 
navicularis of the penis. 

They are described by Skene as tubules which extend for a distance of 
nearly i cm. paralled with the urethra. As a result from inflam- 
mation they can be so dilated that they will admit a No. i probe, and 
even the point of a catheter. 

The urethra is nearly parallel with the bladder, but when the woman 
is erect, it is nearly vertical. 

The urethral mucous membrane, like that of the vestibule, is of the 
pavement variety. The glands are lined at their mouths with pavement 
epithelium, which soon changes into the columnar variety. 



32 



GYNECOLOGY. 



The bladder is situated in the anterior part of the pelvis, between 
the symphysis pubis in front and the vagina and uterus behind. Its 
shape is constantly changing with the accumulation and evacuation of the 
urine. When empty, the urethra forms the stem of a Y, the anterior 
limb of which is the longer. Between the urethra, the anterior surface 




Fig. 32. — ^Vesicovaginal Septum and Base of Female Bladder. Anatomic Relations of 
Ureters at Their Entrance into the Bladder. Contents of Alar Ligament. {Savage). 
I. Ureters. 2, 2. Uterine artery. 3, 3. Uterine veins. 4. Dotted line indicating the 
vaginal end of the uterine cervix. 5. Internal meatus urethrae. 6. Ligamentous process 
of fascia of pubococcygeus muscle and vesicopubic muscles. 7, 7. Pubococcygeus 
muscle. U. Uterine body. O. Ovary, utero-ovarian muscular ligament, and grooved 
Fallopio-ovarian fimbrise. T. Fallopian tube and fimbriae inverted. M. Parovarium. P. 
Pubic arch. V. Body of bladder. 



of the bladder, and the symphysis is a triangular space filled w^th the 
retropubic fat. The bladder, when moderately distended, becomes 
rounded; and when full, oval. The female bladder holds less than that 
of the male, and differs from it also in having the transverse diameter 
longer than the vertical. The bladder is divided into three portions: 



EMBRYOLOGY. 33 

the body, the base or fundus, and the neck. Skene defines the first 
as that portion which lies above a plane formed by the ureteric openings 
and the center of the symphysis pubis. The portion below is the fundus, 
or base, which includes the trigone, or space between the orifices of the 
ureters and internal meatus, and the bas fond, the space immediately 
behind the ureters. The thickened surface about the urethral orifice 
is the neck, which is the most dependent portion when the body is erect. 

The bladder-wall consists mainly of muscular structure. The wall, 
dependent upon the amount of distention, varies from 0.5 to i cm. The 
muscular structure consists of longitudinal and circular fibers, the former 
mostly confined to the anterior and posterior surfaces. They may be 
traced from the vesical neck and pubes in front, where they are called 
the musculi pubovesicales, to the summit, where some of the fibers ac- 
company the urachus. 

The circular fibers are more marked near the vesical orifice, where 
they form the sphincter vesicas. 

The muscular layer is pardy covered externally by the peritoneum, 
which will be discussed later, and internally by the mucous membrane, 
with which it is loosely connected by a layer of fibrous and elastic tissue. 
Because of this loose connection, when the bladder is empty the mucous 
membrane is thrown into folds, except at the trigone, where it is more 
intimately connected with the submucous layer and is much thinner. 

The mucous membrane in life presents a rosy pink appearance, and 
is continuous with that lining the urethra and ureters. Its epithelium 
consists of three or more layers of epithelium resting upon a basement 
membrane. The superficial cells are squamous, but are smaller than 
the vaginal. The inferior layer is composed of columnar epithelium 
with long processes, while the middle one is made up of pyriform cells. 
The membrane is supplied with a rich plexus of fine capillaries and 
nerve-fibers. The latter are not marked in the trigone. 

The bladder is but poorly supplied with lymphatics, and they communi- 
cate with the glands near the internal iliac artery. 

The ureters are the urinary ducts through which the urine is carried 
to the bladder. Their course, pre\dous to crossing the iliac arteries, 
is nearly parallel. The left ureter lies behind the sigmoid flexure of the 
colon. In their subsequent course the ureters extend downward, 
backward, and outward along the lateral walls of the pehds. At 
the spine of the ischium they bend downward, forward, and inward 
to the bladder, passing behind the uterine arteries, and about i to 1.5 cm. 
on each side of the cervix. The distance between the ureters where they 
enter the bladder is 5 cm. They pass obliquely through the vesical wall 
and enter the bladder 2 cm. below and external to the cervix, where their 
orifices are still 4 cm. apart, but united by a prolongation of the longitud- 
inal fibers of the ureter, known as the interureteric ligament. This 
ligament forms a transverse ridge between the two orifices, and serves 
as the base of the vesical triangle. 

The rectum is the lower extremity of the large intestine, and begins 
with the termination of the sigmoid flexure, at the level of the third sacral 
3 



34 



GYNECOLOGY. 



vertebra, to end with the anus. The rectum in its course from the third 
sacral vertebra is directed downward and forward behind the cervix 
uteri and vagina, parallel with the latter, until it turns directly backward 
at the anus. The relation of the rectum to the pelvic structures naturally 
divides it into two portions, the pelvic and the perineal portion. The 
pelvic portion begins opposite the third sacral vertebra and ends at the 
insertion of the levator ani into its wall. The perineal portion lies be- 
tween the muscle and the anus. The space formed by the deviation of 



RECTUM FUNDUS OF UTERUS 



URETER (behind PERITONEUM) 
LOOP OF SMALL INTESTINE 

VERMIFORM APPENDIX 



CECUM (displaced UPWARD) 






fimbriated extremity OF FALLOPIAN TUBE 

SIGMOID flexure (DISPLACED UPWARD) 
LOOP OF SMALL INTESTINE 







DEEP EPIGASTRIC A. / 

OBLITERATED HYPOGASTRIC A 

EXTERNAL ILIAC A. (BEHIND PERITONEUM) 




ROUND LIGAMENT 



BLADDER (DISTENDED) 



APPENDICULO-OVARIAN LIGAMENT 

URACHUS 



FALLOPIAN TUBES 



Fig. 2>l- — Superior View of the Pelvic Cavity. {Deaver). 

the rectum from the line of the vagina is occupied by the perineal body. 
The portion of the rectum involved in this deviation, which is about 2.5 
cm. long, is known as the anus. 

The entire length of the female rectum is twenty centimeters. The 
canal is less curved than in male, and its caliber is greater. The longi- 
tudinal muscular bands so characteristic of the colon are absent. 

The rectum, artifically distended, shows a very large sac, immediately 
above the anus, which decreases as the sigmoid flexure of the colon is 



EMBRYOLOGY. 35 

approached. This very dilatable portion is called the ampulla, and 
when empty, the anterior surface lies in contact with the posterior, so 
that upon transverse section it presents a transverse slit. 

The anal orifice is quite dilatable. The anus forms an aperture which 
closes with its lateral surfaces in contact. The orifice is further obstructed 
by eight or ten longitudinal folds of the mucous membrane. These 
folds are called the "columns of Morgagni," and the depressions between 
them, the ''sinuses of Morgagni." These corrugations are produced by 
the contraction of the sphincter, and disappear when the anus is dis- 
tended. Above the anus are three ring-like zones which are superimposed 
over each other. The first is the zone of the rectal columns and the inter- 
vening sinuses. The mucous membrane upon the surfaces of the columns 
is covered with pavement epithelium, while in the depressions cylindrical 
epithelium similar to that of the bowel above is found. Lieberkiihn's 
crypts are seen only in the upper portion of this zone. Its boundary 
is often recognized as a distinct line, the linea ani rectalis (Hermann). 
The middle zone has a smooth, bright mucous membrane covered with 
pavement epithelium and small papillae. The lower zone is the cutaneous 
zone. This has the horny epithelium well supplied with pigment and 
also connective-tissue sublayer characteristic of the skin. We find here 
papillae, hair, and sebaceous glands adjoining the larger convoluted 
glands of the intestine. The submucous layer consists of a structure of 
quite dense connective tissue, in which are situated the blood-vessels, 
nerves, and lymphatics. Its laxity permits the mucous membrane to 
glide over it. The mucous membrane of the rectum above the anal canal 
has three or four large permanent transverse or oblique semilunar folds 
which often project quite a distance into the lumen of the bowel. These 
folds, according to Gant, are crescent-shaped, capable of some vertical 
motion, and extend about one-half to two-thirds the circumference of the 
rectum and project into its lumen from three-fourths of an inch to an 
inch and a half. They are situated obliquely to the long axes of the bowel. 
They are slightly cup-shaped with the conca\ities looking upward. 
With the bowel distended the free margins of these valves are prominent 
and readily seen through the proctoscope. They are called Houston's 
valves. The number of them is variable; usually there are three. In 
exceptional cases there may be five, six, or even seven. Their location 
is fairly constant. The upper valve is situated at the junction of the sig- 
moid and the rectum on the left rectal wall. The middle, which is the 
most prominent, occupies the right anterior wall opposite the base of the 
bladder and is three inches or more above the anus. The lower valve 
is situated on the left side a short distance below the middle valve. With 
the patient in the knee-chest posture and the rectum well inflated one can 
often see, by the aid of the proctoscope, all these valves at the same time. 
They generally form a sort of spiral stairway which gives a rotatory 
motion to the fecal mass as it progresses toward the anus. 

The rectal wall is composed of three coats — the peritoneal, the 
muscular, and the mucous membrane. 

The arrangement of the serous coat will be considered with the perit- 



36 GYNECOLOGY. 

oneum, but it should be remembered that a portion only of the rectum 
is enveloped by peritoneum. The muscular layer consists of longitudinal 
and circular fibers, but the former are more generally distributed, and 
not collected into bands, as in the colon. The circular fibers are deeply 
situated, and are more marked just above the anus, where they form a 
distinct ring, nearly half an inch in width, which is recognized as the in- 
ternal sphincter. The submucous layer consists of a layer of quite dense 
connective tissue in which are situated the blood-vessels, nerves, and 
lymphatics. Its laxity permits the mucous membrane to glide over it. 
The mucous membrane is continuous with that of the intestine, although 
much thicker and more movable than that of the colon, and its great 
vascularity causes it to have a bright pink or even red color. 

The mucous membrane is lined with columnar epithelium, and con- 
tains a large number of Lieberkiihn's follicles, but no villi. The mucous 
membrane at the anus abruptly changes from the columnar to the pave- 
ment epithelium of the skin, which forms the so-called white line. 

9. Pelvic Peritoneum. That portion of the serous hning of the 
abdominal cavity which is situated within the pelvis, and envelops the 
pelvic organs, is known as the pelvic peritoneum. Upon examination 




Fig. 34. — Curved Dotted Line Shows Covering of the Anterior Uterine Wall by Peritoneum. 

(Winter.) 

of a mesial section it will be seen to leave the anterior abdominal wall 
about 3 cm. above the symphysis and be reflected upon the fundus 
of the bladder. It covers the posterior surface of the bladder to the level 
of the internal os, and as much of the lateral surface as lies behind the 
obliterated hypogastric arteries. (Fig. 34.) From the bladder it crosses 
over to the uterus, the anterior surface, fundus, and entire posterior surface 
of which it invests. (Fig. 35.) Laterally from the anterior surface it 
extends outward upon a plane perpendicular to the pelvic brim, and is 
attached to the lateral wall of the cavity, thus forming the anterior fold 
of the broad ligament. The peritoneal investment extends over the 
uterus posteriorly and upon the upper part of the vagina, nearly 3 cm. 
below the uterovaginal junction. The lateral prolongation of this 
portion forms the posterior border of the broad ligament. The 
broad ligament contains the round ligament in its anterior fold; the 
Fallopian tube in its superior border, between the anterior and posterior 



EMBRYOLOGY. 



37 



folds; and its continuation from the termination of the tube is known as 
the infundibulopelvic ligament whose integrity is of importance in 
maintaining the ovary, and even the uterus, in position. Resting upon 
and projecting from the posterior fold, when the patient is erect, is the 
ovary, which is attached to the uterus by the ovarian ligament. The 
anterior and posterior leaflets of the broad ligament are separated, 
in addition to the structures named, by considerable loose, vascular, 
connective tissue, and afford entrance for the ovarian and uterine 
arteries and nerves, and egress for the veins and lymphatics, while 
its base is penetrated by the ureter on its way to reach the bladder. 
From the vagina the peritoneum is reflected backward, to be attached to 
the anterior surface of the rectum and to the tissues in front of the sacrum. 
Above the promontory of the sacrum it is continuous with the posterior 
abdominal peritoneum. 

The reflection of the peritoneum over the uterus and its extension 
as the broad ligaments upon each side divide the pelvis into two culdesacs: 




Fig. 35. — Posterior Surface of Uterus Showing Extent of Peritoneum; also Fallopian 
Tubes, Ovaries, and Ovarian Ligaments. {Winter.) 



the anterior, or vesico-uterine, and the posterior, or uterorectal. The 
posterior culdesac is further divided by a prolongation of muscular struc- 
ture from the sides of the uterus backward to the iliosacral synchondrosis, 
over which the peritoneum is reflected. This forms a deep, cup-shaped 
cavity directly behind the uterus, which is known as the pouch of Douglas. 
This pouch dips deeper on the left side, and sometimes extends to the 
upper border of the perineal body. When the bladder is empty and the 
nonpregnant uterus lies forward, the coils of small intestine usually occupy 
this pouch, except 'at its very lowest point, and intra-abdominal pressure 
sometimes cause its dissection downward until a distinct hernia occurs 
behind the uterus. On either side, external to the uterosacral ligaments, 
is a fossa, which is known as the para-uterine pouch. This has been 
called by Polk the retro-ovarian shelf. On the side wall of the para- 
uterine pouch the ureter may be seen beneath the peritoneum. This 
space is occupied by the small intestine. During pregnancy the para- 
uterine pouch is lifted up to the pelvic brim, while Douglas' pouch re- 
mains unaffected. From before backward, we may find the following 



38 



GYNECOLOGY. 



pouches or depressions: first, the pubovesical; second, the vesico-abdominal, 
which is seen only during distention of the bladder, and varies in depth 
according to the point at which the serous lining of the abdominal wall 
is reflected. The vesico-uterine pouch is bounded in front by the bladder; 
posteriorly, by the uterus. This pouch varies less than the others, on 
account of the firm attachment of the peritoneum to the anterior surface 
of the uterus. In the empty bladder the bottom of this pouch is about 
3 cm. distant from the anterior culdesac of the vagina, and the pouch 
rises somewhat as the badder falls. The study of the female peritoneum 




Fig. 36. — ^Vertical Transverse Section of the Pelvis, Showing Peritoneal Pouches. 

I, I. Levator ani muscle. 
{Luschka.) 

renders it evident that it differs from that of the male in not being a 
closed sac, as it communicates with the uterine mucous membrane through 
the orifice of the Fallopian tubes, and is again perforated by the ovaries, 
which project through it. The close relation of the peritoneum to the 
pelvic viscera renders any change in this structure perilous to the nor- 
mal situation and relation of these organs. Inflammatory changes result 
in thickening and cicatrization, which produce temporary, if not per- 
manent, displacements. The fixation of the uterus, compression of the 
ovaries, and obstruction of the orifices of the Fallopian tubes are necessary 
sequels of such alterations. The peritoneum, according to Luschka, 
serves as a sort of diaphragm, dividing the pelvic cavity into two portions; 
the one above may be called the intraperitoneal space, and that below, 
the subperitoneal. In the latter is situated the greater part of the pelvic 
connective tissue. 



EMBRYOLOGY. 39 

10. Pelvic Connective Tissue. Is a loose cellular tissue, which 
acts as a padding for the support and safety of the pelvic organs. This 
structure is continuous with that which exists in other portions of the 
body. It appears in the pehis in two varieties: first, as a loose tissue, 
distributed in an irregular manner around and between organs and 
between the layers of the broad ligaments, where it acts as a support 
to the blood-vessels and folds of the peritoneum; second, as firm, w^ell- 
defined laminae or planes entering into the formation of the pehic floor. 
These have already been described under the name of pelvic fascia. 
The connective tissue is continued behind the symphysis as the retropubic 
fat, and lies there in front of the bladder. Between the base of the blad- 
der and the vagina it is connected rather firmly. On the posterior sur- 
face of the vagina there is a very loose layer connecting it with the rectum. 
A large mass is found on each side of the cervix uteri, forming under the 
broad ligaments what is known as the parametrium, which is united in 
front and behind by a much thinner layer. Over the body of the uterus 
the connective tissue is very slight and contains no fat. The rectum 
and vagina are embedded in considerable masses of this tissue. From 
the uterus and the parametrium a thin layer extends between the leaflets 
of the broad ligament, and serves as a support for the vessels. The 
chief mass of this tissue is situated around the cervix, and extends down- 
ward around the vagina to the insertion of the levator ani muscle. The 
distribution and relation of pehdc connective tissue have been studied in 
different ways. The most valuable method is by the examination of 
frozen or spirit-hardened pelves, by which the position of the tissue, its 
amount, and distribution are recognized. Injections of air, water, and 
plaster of Paris have been made beneath the pelvic peritoneum in order 
to determine the lines of cleavage in the pehic connective tissue and the 
directions in which pus w^ould be likely to burrow. Konig made investiga- 
tions upon the bodies of women who had died from nonpuerperal dis- 
ease shortly after labor. When an, injection is made between the layers 
of the broad ligament, high up in front of the ovary, it first passes into 
the tissue at the highest part of the side w^all of the true pehds; then into 
the iliac fossa, lifting up the peritoneum; follows the course of the psoa, 
and passes but slightly into the hollow of the iliac bone; finally, it separates 
the peritoneum from the anterior abdominal wall some little distance 
above Poupart's ligament, and from the true pelvis below it. Second, 
when the injection is made beneath the base of the broad ligament and 
in front of the isthmus, the deep lateral tissue becomes filled first; then 
the peritoneum is lifted from the anterior part of the cer\dx uteri. Separa- 
tion extends to the tissue in the bladder, and ultimately along the round 
ligament and the inguinal ring, where it separates the peritoneum along 
the line of Poupart's ligament and enters the iliac fossa. Third, an in- 
jection at the posterior part of the base of the broad ligament fills the 
tissues around Douglas' pouch, and then follows the course as first 
described. 

11. The Vascular Supply. The pehic organs and peritoneum are 
supplied through the ovarian, uterine, vaginal, and internal pudic arteries. 



40 



GYNECOLOGY. 



The ovarian arteries, analogues of the spermatic in the male, arise from 
the abdominal aorta just below the renal branches and pass downward 
over the psoas muscles in front of the ureters, enter the broad ligaments, 
and pass to the side of the uterus, near which each divides into two 
branches. The upper supplies the fundus uteri, and the lower anasto- 
moses at the side of the uterus with the anastomotic branch of the 
uterine artery. In its course the ovarian artery gives off branches to the 
ampulla of the Fallopian tube and to the isthmus and also numer- 
ous branches to the ovary. A small branch is given off to the round 
ligament. The uterine artery springs from the anterior division of the 
internal iliac,' passes downward and inward toward the cervix uteri, 




Fig. 



-Distribution of the Uterine and Ovarian Vessels. 



then upward between the layers of the broad ligament in a very tortuous 
course, and anastomoses with the lower branch of the ovarian. This 
portion is sometimes called the anastomotic branch, or the puerperal 
branch, as by its tortuous course it permits the vessel to be straightened 
out during the enlargement of the uterus in pregnancy. The primary 
branches given off by the uterine artery are separated from the peritoneum 
only by a thin layer of muscle-fibers. These give off secondary branches, 
which penetrate the muscular wall in a direction at right angles to its 
mucous layer. They anastomose freely and end in capillary loops in 
the mucous membrane. The vaginal branches spring direct from the 
anterior trunk of the internal iliac, but sometimes are given off from the 
uterine or the middle hemorrhoidal. A special branch of the uterine 
artery to the cervix joins with its fellow of the opposite side to form the 
circular artery of the cervix, and with the vaginal branches forms the 
azygos artery of the vagina. Extensive anastomoses take place between 



EMBRYOLOGY. 



41 



the vessels of the opposite sides. The entrance of the vessels by the broad 
ligament enables one in extirpation of the uterus to control hemorrhage 




20 



Fig. ^S. — Arteries of the Female Pelvic Organs. (Savage.) 
I. Vena cava inferior, receives right and left common iliac veins. 2. External iliac vein. 3 
Abdominal aorta. 4. Inferior mesenteric artery. 5. Right common iliac artery. 6 
External iUac artery. 7. Epigastric artery. 8. Obturator branch of epigastric artery 
g. Internal iliac artery crossed in front by h, the ureter. 10. Uterine artery 
II. Obturatof artery; its course is along with and below m, the obturator nerve. L 
Round Hgament. 12. Inferior vesical arter\'. 13. Vaginal branch from it. 14. Utero- 
cervical artery. 15. Artery of the Fallopian tube. 18. Vaginal artery 17, 17, 17. Sper- 
matic arteries, ig. Pudic artery. 20. Superior vesical artery. 21. Inferior hemor- 
rhoidal artery, joined at 22. another interior vesical branch. 23. Posterior di\ision of in- 
ternal iliac artery, terminates in (24) iliolumbar lateral sacral, and (25) gluteal. 26. Scia- 
tic arteries. B. Bladder, u. Urachus. V. Vagina undistended, resting on R, the rec- 
tum. O. Ovary. T. Fallopian tube. 15. Fallopian branch. U. Uterus. L. Round 
ligament. S. Sacral articular surface of sacro-iliac symphysis. P. Pubic s}Tiiphysis, 
articular surface, a. Pyriformis muscle, b. Gluteus maximus muscle, c. Obtura- 
tococcygeus muscle, p. Spine of the ischium, f. Psoas muscle, g. Linea alba, h, h. 
Ureters, i, j, k, 1. Trunks of sacral nerves resting on the pyriformis muscle, m. Obtu- 
rator nerve, q. Peritoneum covering the transversalis fascia. 

by ligation of the latter. The anterior division of the internal iliac also 
affords the blood-supply to the bladder and rectum. The perineal region 
is supplied by branches from the internal pudic arter)^ — a branch of the 



42 



GYNECOLOGY. 



anterior trunk of the internal iliac. It passes out through the greater 
sciatic notch and enters through the lesser, passing around the spine of 
the ischium. In its course it lies upon the internal obturator muscle, 
and is inclosed with the pudic nerve in a canal formed for it by the ob- 
turator fascia. It gives off the following branches: the inferior hemor- 
rhoidal; transverse perineal; superficial perineal or vulvar artery, which 
is much larger than the corresponding branch in the male — the artery 
of the bulb; profundi branch to the crus clitoridis; and the dorsal artery 
of the clitoris. The round ligament receives a small branch from the 




Fig. 39. — Distribution of the Pudic Artery to the Structures of the Perineum. {Deaver.) 

epigastric artery, which anastomoses with the branch from the ovarian. 
The venous distribution of the pelvis is very abundant, and occurs in the 
form of numerous plexuses, which communicate freely with one another. 
These veins are provided with valves. Consequently hemorrhage from 
an injured part will be very profuse when the whole pelvic vascular 
system is engorged, as during pregnancy. Dissection discloses a vesical 
plexus which lies external to the muscular coat of the bladder. At the 
lower part of the rectum the hemorrhoidal plexus is found situated beneath 
the mucous membrane. The distribution of the veins of the labia is 
similar to that of the arteries. From the superficial portion they drain 



EMBRYOLOGY. 



43 



into the pudic, which communicates with the common iHac vein. The 
large veins from the labia minora open into the pars intermedia above. 
The blood returns from the glans and body of the clitoris through the 
dorsal vein of the clitoris, which communicates with the vesical plexus. 
The vaginal plexuses are situated, one in the submucous tissue and the 
other external to the muscular coat. They communicate with the hem- 
orrhoidal and vesical plexuses, receive the blood from the veins of the 
bulb, and empty into the internal iliac vein. The uterine plexus is very 




Fig. 40. — Relation tof the Urethral and \'aginal Venous Plexuses to the Veins of the Clitoris 
and Bulb. The Right Side of the Pelvis Removed by a Section in Front, through the 
Pubic Body, about an Inch from the Symphysis, and, Behind, through Sacro-iliac Joint. 
(Savage.) 

B. Bladder partially inflated, and b ureter cut just before it enters the bladder. V. Vagina 
distended. P. Section of pubis. R. Rectum. C. CUtoris. S. Sacrum, i. Bulb. 2. 
Its urethral venous process. 3. Lower efferent veins. 4. Dorsal vein of the clitoris. 5. 
Urethral venous plexus. 6. Commencement of vaginal venous plexus. 7,8, 9, 10. 
Sciatic and gluteal veins corresponding to arteries. 11. Uterine veins assisting to form the 
uterovaginal venous plexus. 12. Obturator vein. 13. Internal vein. a. Pyriformis 
muscle, h. Larger sciatic ligament, c. Pubor-, obturatos, and ischio-coccygeaJ muscles. 
d. Suspensory ligament of the clitoris, e. Bulbovaginal gland. /, /, /. Roots of sacral 
plexus of nerves. 



complex, and empties into the ovarian veins. The right ovarian vein 
enters the inferior vena cava; and the left, the left renal vein. The right 
ovarian vein has a valve where it pierces the coat of the inferior vena cava, 
while the left has none. To this arrangement is attributed the greater 
frequency of pain and disease in the left ovary. The ovarian or pampin- 
iform plexus lies between the folds of the broad ligament and communicate 
with the uterine plexus. The ovarian plexus opens into the inferior 
vena cava. At the hilum of the ovary is situated the collection of veins 
known as the bulb of the ovary. The vesical, hemorrhoidal, and vaginal 



44 



GYNECOLOGY. 




Fig. 41. — Veins and Erectile Venous Plexuses of the Female Pelvis (Savage.) 

Bladder. R. Rectum. L. Round ligament. U. Uterus. O. Ovary. V. Vagina. S. 
Sacro-iliac articulation. K. Kidney. T. Fallopian tube. P. Pubic symphysis, a. 
Pyriformis muscle, b. Gluteal muscles, c. Ischiococcygeus muscle, d. Internal obtura- 
tor muscle, e, e. Psoas muscles, f. Linea Alba, g, g. Uters. h. Obturator 
nerve, i. Internal inguinal ring, site of canal of Nuck. j. Urachus. k. Sciatic nerve. 
I. Abdominal aorta. 2. Inferior mesenteric artery. 3, 3. Common iliac arteries 
4. External iliac artery. 5. Vena.cava. 6. Renal veins. 7,7. Common iliac veins. 8. 
External iliac vein. 9. Internal iliac artery. 10. Gluteal. 11. Iliolumbar. 12. 
Sciatic. 13. Pudic. 14. Obturator. 15, 16. Epigastric veins. 17. Uterine vein. 18. 
Vaginovesical venous rete. 19. Spermatic veins. 20. Bulb of the ovary. 21. Vein to 
round ligament. 22. Fallopian veins. 



EMBRYOLOGY. 



45 



plexuses, with the pudic veins, empty into the internal iliac vein, which 
joins the inferior vena cava. From the hemorrhoidal plexus there is a 
communication with the portal system through the superior hemorrhoidal 
vein. 




Fig. 42. — Erectile Organs and Veins of the Female Perineum. (Savage.) 
h, g. Crura clitordis, 1,2. Bulb of the vagina. 3. Vestibular intercommunicating branches. 
4. Veins of the clitoris. 5. Superficial perineal and obturator veins. 6. Veins of 
communication with superficial epigastric veins. 7. Labial branches of pudic. 8,9. 10. 
Pudic vein and primary branches. M. Urethral orifice or meatus. V. Vaginal 
aperture. A. Anus. T. Tuberosity of ischium. O. Coccyx. G. A'ulvovaginal gland. 



12. The lymphatic system comprises: first, the lymphatic glands; 
second, the lymphatic vessels. The lymphatic glands are: the inguinal 
glands, which lie parallel to and just below Poupart's ligament; and the 
pelvic glands. (Fig. 43.) These comprise: (a) a gland situated at the 
isthmus uteri; (b) the hypogastric or iliac glands, which lie beneath the 
peritoneum, in the space between the internal and external iliac vessels; 
(c) the sacral glands, situated on the lateral aspect of the anterior surface 
of the sacrum and the mesorectum; and (d) a gland or small collection 
of glands at the obturator foramen, known as the obturator gland of 
Guerin. 



All discharge into the 



iimbar glands, which lie in front of the 



46 



GYNECOLOGY. 



lumbar vertebrae, and finally into the thoracic duct. The lymphatics 
of the external genitals form an extensive network on the internal aspect 
of the labia majora, over the labia minora, around the vaginal and urethral 
orifices, the vestibule, and the clitoris. All discharge into the inguinal 
glands. As a consequence, syphilis or cancer affecting the vulva or lower 







Fig. 43. — The Lumbo-iliac Lymphatics and Glands. Lymphatics of the Gravid Uterus 

and Appendages, (Savage.) 

I, 2. Superior lumbar glands. 3. Inferior lumbar glands. 4. Sacral lymphatic glands. 
5. External and internal lymphatic glands. 6. Common iliac glands. 5, 7. Spermatic 
lymphatic plexus, a. Left renal vessels, b. Left renal vein. c. Left spermatic vein, 
d. Left spermatic vessels, covered by their lymphatic plexus, e. Aorta, f. Common 
ihac trunks, g. Ascending cava. h. External iliac artery and vein, m, n. Ureters, o. 
Right common ihac vein. p. Iliacus muscle, s. Psoas muscle. O. Ovary reversed, 
showing lymphatics between it and its bulb. 



fourth of the vagina causes involvement of these glands. In the upper 
three-fourths of the vagina and cervix uteri the lymphatics open into the 
hypogastric glands. This is true not only of the lymphatics of the upper 
three-fourths of the vagina and cervix, but also of the lymphatics of the 
bladder. The lymphatics of the uterus pass through the broad ligaments 
with those of the ovary and tube and enter the lumbar glands. Some of 



EMBRYOLOGY. 



47 



the uterine lymphatics pass along the round ligaments to the glands of 
the groin. Leopold, in investigating the lymphatics in the unimpreg- 
nated uterus, regards the mucous membrane of the organ as a lymphatic 




Fig. 44. — Nerves of the Unimpregnated Uterus with the Nerves of the Chtoris. (Savage.) 
t. Hypogastric plexus. 2. Rectal branch of inferior mesenteric plexus. 3. A lumbar o-ang- 
lion of the sympathetic. 4. Spermatic plexus, supplies Fallopian tube, ovary, and part of 
the uterus. 5. Branches from third and fourth sacral, aiding to form 6, 7, right inferior 
hygogastric plexus. 8. Uterine filaments. 9. Vesical plexus and branch. 10. Trunk of 
great sacrosciatic nerve. 11. Muscular branch of the fourth sacral nerve. 12. Trunk 
of pudic nerve. 13. Continuation of 12 into dorsal nerve of the clitoris. R. Rectum. U. 
Uterus. B. Bladder. D. Transversus perinei muscle cut across. S. Section of ilium. 
P. Section of s}Tnphysis. 

surface consisting of lymph-sinuses covered with endothelium. The 
lymph passes from these spaces into the vessels of the muscular coat, 
and flows into the larger vessels which enter the broad ligaments. The 



4o GYNECOLOGY. 

distribution of these vessels and their extensive character account for 
the rapidity with which septic matter is absorbed from the uterine cavity 
and explain the various routes by which bacteria can pass through lym- 
phatic canals or penetrate the blood-vessels. 

The lymphatics of the rectum lie in the mucous and muscular layers 
and communicate with the glands of the mesorectum or the sacral glands. 

The nerves distributed to the pelvic organs are derived from the spinal 
and sympathetic systems. The branches from the spinal nerves consist 
of the inferior hemorrhoidal branch of the pudic, from the fourth and 
fifth sacral, and of the coccygeal nerves. These supply the levator ani, 
sphincter, and coccygeus muscles; the muscles of the perineum and clitoris 
are supplied by branches from the internal pudic, which nerve terminates 
in the nervous plexus of the glans clitoris. (Fig. 44.) The hypogastric 
plexus, derived from the sympathetic, lies between the common iliac 
arteries, and distributes branches, which are reinforced by others from the 
lumbar and sacral ganglia and sacral nerves, to form the inferior hypogas- 
tric plexuses, one of which is situated on each side of the vagina. These 
plexuses distribute filaments to the vagina, uterus. Fallopian tube, and ovary. 
The pelvic, splanchnic, and hypogastric nerves are motor and sensory 
to the bladder; the pudic is motor to the sphincter; and all the nerves of 
the vagina and clitoris are sensory to the skin of the perineum, and es- 
pecially so to the mucous membrane of the glans clitoris. The terminal 
filaments in the uterus are found in the nuclei of the unstriped muscle. 
Those of the mucous membrane are said to end in the ganglia. End- 
bulbs have been found in the clitoris and vagina. In the ovary the nerves 
pass to the Graafian follicle and to the walls of the membrana granulosa. 

13. Consideration of the Pelvic Organs and Structure Studied 
as a Whole. In the upright position the plane of the brim of the pelvis 
is at an angle of 60 degrees to the horizon. The fundus of the uterus 
lies just below this plane, with its axis at right angles to it, and conse- 
quently at right angles to the vagina, which is parallel to the brim of 
the pelvis. In the upright position the internal abdominal pressure is 
directed against "the symphysis and the posterior surface of the fundus 
of the uterus when in its normal situation. 

The uterus, as we have seen, is freely movable — swung in its position 
in the pelvis by the ligaments. The broad ligaments support it in the 
center of the pelvis, and by their position and relation serve to assist in 
maintaining it in an antefiexed position. The round ligaments are an 
additional stay, and, when of normal resiliency, draw the fundus forward. 
The other ligaments are the uterovescial and the uterosacral. The for- 
mer consist of a continuation of the peritoneum from the bladder to the 
uterus; the latter of folds of peritoneum which also contain muscle fibers 
derived from the superior muscular layer of the uterus. The function of 
these filaments is to hold back the cervix while the intra-abdominal 
pressure maintains the fundus forward. Increase in the weight of the 
uterus; increased intra-abdominal pressure and deviations from the normal 
inclination of the pelvis; for the proper resiliency and tone of the liga- 
ments; and from the natural relations and support of the vagina, are all 



PHYSIOLOGY. * 49 

factors in the production of uterine displacements, especially in that form 
characterized by descent. The plane of the pelvic outlet when the patient 
is erect forms, in front, an acute angle with the horizon. The urethra, 
the vagina, and in the upper part of its course, the rectum, are parallel 
to the plane of the brim of the pelvis. The lower portion of the rectum 
turns acutely backward and forms an axis at right angles to that of the 
vagina. This portion, the anus, looks backward and downward; conse- 
quently the introduction of the finger or nozzle of a syringe must be 
directed forward and upward, or directly toward the vagina, and after 
passing into the anus is carried upward and backward. On median 
vertical section the vagina will be seen as a mere slit, slightly S-shaped, 
the lower part of its posterior wall presenting a convex surface anteriorly. 
Consequently, the pelvic floor is divided into two segments, the anterior 
and upper of which rests on the more fixed posterior segment. The 
rectum at the anus forms ah anteroposterior slit. 

Intra-abdominal force first causes pressure of the anterior segment 
against the posterior, and then a sliding backward of that portion of the 
inferior segment in front of the anterior wall of the rectum. 

PHYSIOLOGY. 

14. Function. The important functions of the genital organs are 
the processes associated with reproduction. These comprise alterations 
in the organs by which menstruation is established, repeated monthly, 
and finally discontinued; the relation of the sexes in copulation; the 
fecundation of the ovum, its subsequent nutrition, and the procedure by 
which the matured product attains a separate existence. 

The transition from child to woman, indicated by the appearance of 
menstruation, is denominated puberty. 

The completion of development, which fits the individual for the 
processes of maternity, is called nubility. 

The deposit of the vitalizing principle of the male within the body 
of the female occurs through the act of copulation, and its union with the 
ovum, resulting in the establishment of a new life, is known as fecundation. 

The nutrition of this vitalized structure and its subsequent course of 
development are recognized as gestation. 

The processes by which the matured product secures a separate 
existence are known as parturition. 

The first three of these functions and their variations from the 
normal comprise the field of gynecology. 

15. Puberty. The completion of the developmental process that 
results in the establishment of menstruation and ovulation has been 
called puberty. It marks the transition from the child to the woman, 
and occurs between the thirteenth and fifteenth years. The age of the 
individual differs under varying circumstances. Puberty occurs earlier 
in the natives of hot climates than in those of the north, and earlier tn 
the Latin races than in the Anglo-Saxon. City girls mature at an earlier 
age than those raised in the country, and those raised in affluence sooner 



50 • GYNECOLOGY. 

than the poor. The occurrence of the phenomena of menstruation prior 
to the age of thirteen is called precocious puberty. Such instances are not 
infrequent. Isolated cases in which puberty is manifested at a very 
early age. Rein reports a girl of six years whose pubis was covered 
with hair. She menstruated regularly for a year. The New York 
Medical Record, i6, xi, 1895, reports a girl who, when ten years of age, 
gave birth to a child. 

Retarded or delayed puberty is caused by chlorosis, general ill health, 
plethora, or some congenital deformity of the genital tract. Numerous 
instances are recorded where women have given birth to children prior to 
the establishment of menstruation. In other words, ovulation may occur 
without being followed by menstruation. 

The advent of puberty is manifested by the following characteristics 
in addition to menstruation: the figure becomes more rounded, from an 
increase of adipose tissue; the breasts enlarge and frequently become 
painful; hair grows upon the mons veneris and labia majora; there is an 
increase in the quantity of blood; development of the glandular structure, 
particularly in the uterus and the mammary gland; and marked changes 
in the nervous system. According to Christopher Martin, '^ there is a 
remarkable transformation in the psychic, emotional and mental life of 
the girl. The current of her thoughts is mysteriously changed. Hopes 
and yearnings before unknown thrill and agitate her, and life acquires a 
new and deeper meaning. These profound and subtle changes are not so 
difficult to understand if we accept the view that puberty means the 
sudden bursting into activity in the midst of the nervous system of a 
hitherto dormant center." 

The glandular development of the mammae may be rapid at times so 
rapid as to simulate a tumor. The age of the individual should prevent 
error in diagnosis. 

16. Nubility. The advent of puberty indicates that the conditions 
and functions are established that will permit procreation, but the structures 
are not sufficiently developed to render the individual suited for favorable 
reproduction. Experience has demonstrated that the mortality is much 
greater among those who come to the completion of gestation prior to 
the age of twenty. Women coming to early maternity mature early, 
reach the menopause at an early age, and are prematurely aged. 

17. Menstruation and Ovulation. Menstruation — also called the 
menses, the monthlies, the courses, the turns, the sickness, and the periods 
- — has been defined by Sutton as the "periodic discharge of blood from 
the uterus, accompanied by the shedding of the epithelium of the body 
and fundus, as well as of that lining the utricular glands near their orifices." 

Ovulation is the discharge of an ovum from a matured Graafian 
follicle. These two processes are considered here as having a direct 
relation, though we have no positive proof that the one may not occur 
without the other. Indeed there is determinative evidence that occa- 
sionally they are independent. The frequent occurrence of pregnancy 
prior to the advent of puberty and subsequent to the climacteric is an 
indication that ovulation can occur without menstruation. 



PHYSIOLOGY. 51 

The investigations of Frankel and others justify the following theory 
regarding the corpus luteum and its influence on the menstrual function. 

1. The corpus luteum is a gland with an internal secretion. Follow- 
ing each ovulation, this gland is redeveloped in the functionating ovary 
and its secretion dominates the occurrence of menstruation. 

2. The secretion of the corpus luteum entering the blood determines 
the nutrition of the uterus, especially that of its endometrium, in whose 
connective tissue it excites extreme hyperplasia and hyperemia. 

3. It prepares the uterus for the reception, retention and nutrition 
of the fecundated ovum, and where fecundation has not taken place, 
establishes the menstrual flow. The acceptance of the above hypothesis 
gives an intelligent explanation of the periodical occurrence of menstruation 
and its variations. Menstruation, in the majority of women, occurs 
every twenty-eight days. The intervals may vary from twenty-one days 
to five or six weeks. It does not occur at an absolutely definite date in 
the same individual. 

The quantity of blood lost is difficult to determine. The average 
amount is estimated to be three to five ounces. The duration of the flow 
varies, but less than two, or more than eight days indicates an abnormal 
condition. Absent, or greatly decreased flow is known as amenorrhea. 
The prolonged or excessive flow is called menorrhagia. When the func- 
tion is associated with severe pain, it is dysmenorrhea. The menstrual 
discharge is not pure blood, but consists of a dark bloody fluid, thin and 
slimy in character, which contains, as revealed by the microscope, blood- 
corpuscles, leukocytes, epithelium, and stroma. The normal menstrua- 
tion is not clotted, due to the admixture of the secretion of the uterine and 
cervical glands. It is only when the flow is excessive or the gland secre- 
tion deficient that clots are present. 

Menstruation occurs only in women and in certain monkeys; it is 
apparently limited to those animals that maintain the erect position. 

Menstruation involves between thirty and thirty-five years of the life 
of woman. This is known as the period of active sexual life, beginning from 
the thirteenth to the fifteenth years and continuing from the forty-fifth 
to the fiftieth. The final cessation, like its advent, may be advanced or 
retarded by various causes. Each menstrual period is generally pre- 
ceded by some premonitory symptoms, a sense of weight, pressure, or 
uneasiness extending down the limbs, a sense of exhilaration, an increased 
vascular tension, and, Belfield asserts, an increase of weight which may 
exceed one pound an hour for several hours, the women gaining seven 
to nine pounds in twenty-hours. This increment, he says, is due: i, to in- 
creased absorption of oxygen; and, 2, to decreased elimination. With the 
establishment of the flow she suffers from depression, languor, malaise, 
disinclination for exertion (either physical or mental), and, according 
to Belfield, decrease in weight. Many women will exhibit a tendency to 
the occurrence of gastro-intestinal disturbance, or the formation of 
toxins developing an autointoxication, which will produce migraine, 
aggravate nervous manifestations, chorea, epilepsy, and even delusions. 
Epilepsy and insanity are frequently so marked and recur so regularly 



52 



GYNECOLOGY. 



with the menstruation as to lead the family and physician to believe the 
disorders are the result of diseased conditions of the pelvic organs. 

During the menstrual process the uterus and pelvic viscera become 
engorged with blood; the uterus is enlarged, turgid, and sensitive; during 
the process of engorgement the glands become filled with epithelium dis- 
charged from the external portion of the gland. Many of the cells are 
liquefied, increasing the quantity of mucus. With the establishment 
of the flow the engorgement is relieved and the general disturbance sub- 
sides. It is probable that these manifestations are due to the disturbed 
balance between the internal secretion of the ovary and those of the other 
ductless glands. Following the period, the mucous surfaces are grad- 













Fig. 45. — Changes of Uteiine Mucous Membrane During Menstruation. 



(Wider.) 



ually regenerated from the epithelial tissue remaining in the glands, 
until, at its completion, the structure is again renewed. The blood 
escapes from the capillaries by diapedesis, in places raises the epithelium, 
in others fractures it, so that its loss is much greater during the flow. The 
menstrual flow is synchronous with the maximum activity of the gland 
known as the corpus luteum, and follows ovulation some two weeks. 
Should the ovum become fecundated, menstruation in the majority of 
cases fails to occur. The menstrual discharge comes from the entire 
cylindric epithelium-lined mucous membrane. My own researches, 
confirmed by those of many others, are sufficient to demonstrate that the 
Fallopian tubes as well as the uterus take part in the menstrual flow. 
It is not unreasonable to suppose that the presence of bloody fluid in the. 



PHYSIOLOGY. 53 

tube is of value in promoting the nutrition of the fecundated ovum and 
that the consequent distention of the tube facilitates the passage of the 
ovum to the uterus. 

The theory of the determination of menstruation by an internal secretion 
formed by the corpus luteum seems justified by the following phenomena : 

1. The ovary furnishes the ovum. It is the function of the uterus 
to retain and nourish the ovum until its product is ready for a separate 
existence. Hence, the producer rather than the retainer should dominate 
the function. 

2. The entire removal of ovarian structure invariably results in the 
cessation of menstruation. 

3. Removal of the ovaries is generally followed a few days later by 
the occurrence of a vaginal discharge which cannot be distinguished from 
the ordinary menstruation. 

4. Strassman's experiments of injecting the structure of the ovary 
with sterilized water were followed two days later by a discharge from 
the uterus which in every way resembled menstruation. 

5. The destruction of the corpus luteum is followed by lapse of the 
subsequent menstrual period. 

The occasional occurrence of a bloody discharge after the removal 
of both ovaries has been held to negative our second proposition, but my 
experience leads me to doubt the regular recurrence of menstruation 
after the removal of both ovaries. An occasional bloody discharge from 
the genital tract after the extirpation of both ovaries means nothing more 
than the relief of some local congestion. 

It is only when the ovaries and utricular glands attain a development 
that renders their secretion capable of exerting a dominating influence 
that puberty occurs, and the process continues until these structures 
begin to atrophy and cease to exert their governing course. Napier 
denies the probability of the period being produced by ovulation and 
cites, as presumptive evidence, the occurrence of the latter without men- 
struation and the continuation of menstruation after the removal of both 
ovaries. Many other theories are advanced for the periodic occurrence 
of menstruation. Johnstone believed in a special menstrual nerve 
plexus, situated near the cornua of the uterus; but this structure has not 
been recognized by any other observer. 

Menstruation continues during pregnancy only as the rarest exception, 
and the functional activities of the ovaries is suspended during lactation. 
Neither ovulation nor menstruation is likely to occur during lactation. 
Many women prolong the period of lactation for the purpose of render- 
ing themselves less susceptible to fruitful coition. 

18. The menopause, or the conclusion of menstrual activity, is 
regarded as a critical period in woman's existence. It is variously de- 
nominated as the menopause, the climacteric, and the change of life. 
The menstrual life of woman lasts, upon an average, nearly thirty-five 
years, so that the menopause should occur between the forty-seventh 
and fiftieth years. Its occurrence may be accelerated or retarded by 
various causes. 



54 GYNECOLOGY. 

The term menopause is employed to designate the period of the 
change. The average duration of the menopause is about two and one- 
half years. A few fortunate persons continue to menstruate regularly 
until a certain period, when the flow discontinues, never again to recur. 
Others continue irregular for six months, when it ceases. Generally 
a patient will notice that the periods are getting more scant, until finally 
she misses one or two periods; then menstruation recurs for a while, to 
subside again, thus continuing irregularly for one of two years. The 
irregularity may be prolonged over a period of four or five years. While, 
as a rule, the intervals are longer, the periods may occur more frequently, 
with intervals of but twenty-one or even fourteen days. 

The flow may be increased, and occasionally hemorrhages occur 
without any assignable cause. 

Excessive or prolonged bleeding should always be a cause of anxiety, 
and should lead to a careful examination in order to determine its cause. 
The cause should not be assigned to change of life until careful investiga- 
tion has eliminated every other source. The occurrence of menstruation 
is attended with the elimination of certain materials from the blood. 

Chemic changes in the blood and tissues are constant, and the elimi- 
nation of the albuminoids during menstruation is demonstrated by a 
more marked alteration of the blood following menstruation than the 
mere blood-loss would produce. 

Premature menopause occurs prior to the age of thirty-two years. It 
may be induced by shock, severe illness, prolonged anxiety, overstudy, 
mental affections, disease of the ovaries (such as destruction of the ovarian 
stroma by double ovarian tumors), sepsis, chronic disease of the append- 
ages, and some forms of metritis. A rapid increase in adipose tissue is 
associated with some cases. 

Early menopause occurs between the ages of thirty-two and forty- 
two years. It occurs early in the virgin, and earlier in blonds than in 
brunettes. Fat women reach the menopause early. Occasionally the 
menopause occurs at an early age without any assignable cause. 

Retarded or Delayed Menopause. The occurrence of the menopause 
is distinctly affected by heredity. It may be delayed by child-bearing, 
uterine growths, or malignant degeneration. Robertson reports the case 
of a woman who ceased to menstruate for twelve months at the age of 
fifty years, when the flow returned and continued until her death at seventy. 
Saxonia speaks of a nun who had a return of her menstruation at the 
age of one hundred years, which continued regularly until she died three 
years later. 

When menstruation is arrested by anemia or pregnancy, we see in 
the skin marked deposits of pigment and other materials that would 
be eliminated by its occurrence. 

When the menopause occurs suddenly (either as a result of the re- 
tained products or a want of balance in the action of the internal secretion 
from the ductless glands) an intoxication follows which causes various 
nervous perversions. Peculiar vasomotor disturbances are very usual, 
such as sudden sensations of heat; flushings; waves of blood rolling up 



ETIOLOGY. 55 

to the face, accompanied by a sensation of giddiness, suffocation, or 
oppression; cold, clammy perspiration; shooting neuralgic pain; head- 
aches; fullness of the vessels of the head and neck; palpitations; gastric 
irritation; diarrhea; irritability of temper; melancholia; and disturbed 
mental balance. 

In sudden production of the climacteric after radical operations the 
vasomotor disturbances are frequently so distressing as to render the 
condition for which the operation was performed preferable. 

19. Copulation is that act of union by which the vitalizing principle 
of the male is deposited in the genital organs of the female. The sexual 
desire of woman is much less marked than that of man. Frequently 
she has no sexual sensation, the act is even repugnant, but she yields 
to the man's embrace from her wish to gratify his desire. Such a woman, 
mated to a man of impetuous inclination, often becomes a sexual slave. 
The clitoris and the tissues about the vestibule are erectile, and take part 
in the orgasm, during which a secretion is ejected from the vulvovaginal 
glands. 

Imperfect or unsatisfactory copulation is a prolific source of disease. 
Efforts to avoid the legitimate results of copulation, like all violations of 
nature's laws, visit their penalty upon both the offenders, but most 
heavily upon the woman. 

20. Fecundation is the union of the spermatozoid with the o\Tim 
and the successful fertilization of the latter. Its occurrence does not 
require that the woman should share in the pleasurable sensation of copula- 
tion; indeed, it can follow in spite of the fiercest resistance upon her part. 
The spermatozoids, the active fertilizing agents from the man, require 
no assistance from the woman, but by a vermicular motion can make 
their way to the ovum in the internal organs. 

There has been much discussion over the probable point at which 
fertilization occurs and as to the ability of the spermatozoa to penetrate 
the narrow isthmus of the Fallopian tube against the waving cilia, the 
function of which is to promote a current toward the uterus. The demon- 
stration that they overcome these obstacles in the sheep and other lower 
animals, and are found swarming over the ovary, and the frequent oc- 
currence of ectopic gestation in the woman, should be accepted as a 
sufficient demonstration that they make the voyage. It is most probable 
that fecundation results in the tube, from which the vitalized ovum passes 
into the uterus, which is prepared for its reception. 

Impregnation is more likely to occur during or immediately following 
menstruation; less likely, immediately preceding the flow; and the woman 
is least susceptible in the mid-interval. 

Independent of organic conditions, there is a marked difference be- 
tween individuals as regards their susceptibility to impregnation. 

ETIOLOGY. 

21. The Importance of Etiology. A knowledge of the causes 
which produce disorders of the genital tract is essential to the ready recog- 



56 GYNECOLOGY. 

nition of their character and employment of proper measures for the 
rehef of the suffering victim. The study of the forces which combine for 
the production of genital disorders is especially complex. Not only do 
they comprise the actions of the diseased, but also of those with whom she 
is associated — particularly those who have been her progenitors. Here, 
truly, we see the sins of the parent visited upon the children beyond the 
third, to many generations. 

22. Classification. The causes of diseases are sometimes divided 
into two great classes, the predisposing and the exciting. When con- 
sidering some particular class of disease, as, for instance, inflammation, 
such classification can be arranged readily, but when we come to consider 
all the disorders to which the genital organs are subjected, it becomes more 
difiicult to declare which are predisposing and which are exciting. In one 
individual the diseased state can be traced directly to abnormalities in 
development; in another to defects in her manner of life; the third may 
have had the disease brought to her through her sexual life; while a fourth 
suffers from injuries incident to reproduction. 

The following classification seems comprehensive: 

a. Hereditary and congenital; 

b. Hygienic; 

c. Sexual; 

d. Traumatic; 

e. Infective; 

f. Incidental to age. 

a. Hereditary and Congenital Causes. It seem impossible, although 
demonstrated day by day, that the atoms, supplied by the male and 
female, which unite to organize processes of construction for a new life, 
contain within their minute compass the impetus which is to lead to the 
development of traits and characteristics similar to those possessed by 
their progenitors. 

These involve not only shade, form, and color, but mental and moral 
attributes. Imperfections and unfortunate traits which are common to 
the parents are intensified in the offspring. A knowledge of such trans- 
mission is employed by the stock raiser to improve his herds. Only 
such males are employed as will improve and correct the recognized 
defects of his herd. While it is impossible to introduce the precision of 
the stock breeder in the relation of the sexes of the human race, it cannot 
be denied that the production of healthy offspring is too rarely the motive 
for union. Family, position, and wealth are more frequently considered 
essential than are good health and good morals upon the part of the elected 
husband. The worn out roue, the debauched or decrepit son of wealth 
is preferred to the virile young man who has his fortune to make. A 
feeble or sexually exhausted male united to a cold, dispassionate woman 
with little or no inclination to maternity must result in the production of 
offspring with still lower sexual virility. Sterility, defective sexual and 
physical development, and lessened powers of resistance are likely to 
characterize the offspring of such a union. Intemperance in eating and 
drinking, overwork, exhaustion from indulgence in the exigencies of 



ETIOLOGY. 57 

fashionable life, and a tendency to marked fat production in one or both 
parents, lessens virility and vitality in the children. Intensification of 
pre-existing traits, the occurrence of vicious tendencies, lessened resist- 
ance to certain constitutional diseases as tuberculosis, the gouty diathesis, 
and malignant degenerations may be transmitted from parent to child 
and are known as hereditary causes of disease. Not infrequently as a 
result of careful hygiene, improved environment, and other favorable 
conditions such tendencies may not make their appearance in one or more 
generations and apparently become intensified in one less favorably 
situated. The most marked influence upon the sexual life of the indi- 
vidual will be recognized in the study of the development of the ovum. 
During its progress of development the ovum is subjected to various 
disorders which may lead to arrest or deranged formation of the structures 
of the genital tract, dependent, of course, upon the period or stage of 
development in which this may take place. Should the change Occur 
before the separation of the Mlillerian ducts and the genital bodies 
from the Wolflian, there may be an absence of the structure upon 
the side affected, so that kidney, ovary, tube, and one horn of the uterus 
are wanting. (See Malformations.) In the latter stages of develop- 
ment one or both Mlillerian ducts may be affected, resulting in absent, 
rudimentary or defective uteri. The ducts may fail to coalesce; form 
apparently well developed uteri and vagina, with a septum between; 
or the coalescence may be partial. Failure to coalesce causes the 
development of separate and generally rudimentary uteri and vagina. 
Partial coalescence may involve only the vaginal portion of the tubes, 
with the two horns of the uterus completely separated, making a double 
uterus, or it may be a bicornate uterus joined together with a com- 
mon neck; or the division may be in the fundus of the uterus only. 
In the development of the tubes, the inflammatory process, which results 
in the arrest of development, may affect one tube only, while the other 
goes on to full development. The rudimentary duct may encircle to 
some degree the well developed organ. Such a condition may result in 
the development of a uterus which is unequal to the proper performance 
of its functions and endanger the life of the woman in a subsequent 
gestation; or the horn may be so well developed as to carry on its functions 
without the abnormality being suspected until some operative procedure 
discloses the actual condition. The rudimentary horn may in some cases 
be associated with an atresia of the corresponding vagina. Such a con- 
dition would not attract attention until puberty, when fluid unable to 
escape would accumulate in the defective tube, forming a more or less 
definite tumor. Such a tumor may be situated to one side of the vagina, 
but more frequently points somewhat anterior to the well formed canal. 
A woman who had given birth to two children came under my observation, 
and had at that time a large interstitial fibroid growth in the uterus. 
Examination revealed, anterior to and to the right of the vagina, a pouch 
whose character was not recognized until the operation when it was 
found to be the blind pouch of a rudimentary uterus. The septa which 
occasionally divide the vagina produce no appreciable effect during 



$8 GYNECOLOGY. 

virginity and are not likely to be discovered until after the marriage of the 
individual. A septum produces so small a tube as to lead to discomfort 
and pain during the marital relations and to obstruction during parturi- 
tion. Of course, in the latter, the amount of obstruction will depend 
upon the thickness and firmness of the septum. Generally it is torn 
through the greater part of its extent during parturition. Occasionally, 
subsequent to parturition, a bridle or remnant of this septum will be found 
connecting the anterior and posterior wall of the vagina, the remaining 
portion of it having either been torn through or sloughed away as a result 
of parturition. Defective development may involve the lower part of 
the genital tube, the vagina and vulva. Thus, there may be an absence 
of the urethra, a condition of hypospadias, in which the urethra opens 
into the vagina. A portion of the vagina may have undergone atresia 
or the vulvar orifice of the vagina be closed by an imperforate hymen. 
These conditions are not likely to produce symptoms until the woman 
has reached and passed the period of puberty, when the occurrence 
of the menstrual molimina without the presence of a discharge indicates 
something abnormal. If the condition is not recognized a tumor will 
ultimately develop from retention of the menstrual discharge. Deform- 
ities may affect the labia majora and the labia minora, the former being 
thin; there may be a slight amount of fatty tissue; or the inguinal canal 
may remain large, permitting the secretion from the peritoneal cavity to 
descend into a sac, forming a hydrocele; or the intestine may push down 
causing hernia. The labia minora may be elongated or almost absent. 
The clitoris may be defective in its development, or so large and hyper- 
trophied as to lead to doubt as to the sex. This malformation may affect 
the genital organs of either sex, giving rise to uncertainty as to the sex of 
the individual under consideration, when it is known as hermaphroditism. 
True hemaphroditism, the presence of both organs in the same individual, 
probably does not exist. Pseudohermaphroditism, or a condition in which 
the organs of one resemble those of the other sex, are quite frequent. 
Malformations of this character, which have occurred during the prog- 
ress of the development of the ovum, are known as congenital conditions 
in contradistinction to those we have been considering as hereditary. 

b. Hygienic Causes. Woman is like a flower. To reach the highest 
development she must absorb generously the rays of the sun and drink 
deeply of pure air. Unfortunately, the tendencies of civilization have 
been to deprive her of these essentials at the period of life when she is in 
most need as she enters into womanhood. Her male companions, with 
whom until this time she has enjoyed almost equal freedom, are still 
permitted to enjoy the freedom of nature, while she is condemned to 
interest herself with indoor pursuits. No longer allowed to romp and play 
she is doomed to practise being a lady. Stiffly and often tightly dressed, 
she is compelled to assume the attitude and thoughts of a mature woman, 
and what exercise she secures is taken so sedately as to be unworthy 
of that designation. At the period of life when the development of her 
sexual functions are making the greatest draft upon her nervous system, 
she is confined closely to her books and music, securing the accomplish- 



ETIOLOGY. 59 

merits and embellishments which are to be her capital. At an early age 
she is introduced to society, and if fortunately ( ?) situated her life becomes 
a continuous whirl of parties and entertainments entailing late hours, 
irregular meals, undue exposure, excitement, and a continual appeal 
to the emotions. Her social position demands that the natural contour 
of the body be distorted by tight dresses, which displace the viscera from 
their normal relations, increasing intra-abdominal pressure, and driving 
the pelvic organs to a lower level. The circulation in these organs is 
necessarily influenced by the interference with the venous return, thus 
causing stasis. The compression of the lower part of the chest inter- 
feres with the expansion of the lungs, with the action of the stomach, 
heart, and liver, so that the processes of nutrition are afifected, and the 
individual suffers from anemia, neurasthenia, defective action of the 
digestive tract, and disturbances of the functions of the genital organs. 
The faults enumerated are still further enhanced by enveloping the 
central portion of the body with skirts supported from the waist, while 
the extremities are clad in network hose and thin shoes or slippers, and 
the neck, chest, and arms bare. Ordinarily she will go fairly clad and 
make the above changes in the coldest weather; occupying crowded rooms, 
subject to drafts — this regardless of the menstrual periods. Should it 
be surprising that serious pelvic disorders are frequent and pelvic disease 
is the rule rather than the exception ? The usual life of the young woman 
precludes regularity in the performance of her functions. The evacuation 
of her bowels and bladder are neglected. Retention of the contents of 
these viscera produce repeated displacements of the uterus which finally 
become permanent. The failure to evacuate the bowels causes a toxemia 
which profoundly influences nutrition and produces toxic symptoms, 
in which the pelvic organs have a considerable part. 

Want of general cleanliness necessarily has a marked influence upon 
the health and nutrition of the individual. The skin takes a very active 
part in the processes of elimination and must be kept in good condition 
by proper and systematic bathing to do eft'ective work. Neglect of 
local cleanliness results in the decomposition of the accumulating secre- 
tions from the vaginal tract and the sweat and sebaceous glands of the 
vulva, which are to some degree soiled with urine. Such an accumulation 
forms an excellent culture fluid for micro-organisms and diseases of the 
vulva and vagina are thus produced. The retention of the smegma 
beneath the prepuce of the clitoris leads to irritation and adhesions 
between it and the glans, to irritation of the bladder, frequent 
micturition, wetting of the bed, to nervous disorders, sometimes con- 
vulsions, and frequently to masturbation. 

c. Sexual Causes. With the development of puberty the sexual instinct 
dominates the female organism. Her viewpoint of life changes. How- 
ever exalted her ambition to attain eminence in some unusual line the 
impetus to maternity cannot be extinguished. Less passionate, less 
lustful than man, she yet clings with greater constancy and devotion to the 
companion of her choice. Her more limited sphere of action in life; 
her more delicately organized nervous system, renders her especially 



6o GYNECOLOGY. 

susceptible to the influence of the emotions. While the sexual desire 
or eroticism varies in individuals, the majority of women yield to the 
sexual relation through a desire to please the man rather than from any 
sexual inclination, from a desire to gratify rather than to be gratified. 
Many women experience no sense of pleasure during or as a result of the 
sexual act, and regard it as only a means to an end; that is, the retention 
of the affections of her companion and the production of offspring. Some 
women experience so much physical discomfort during the act and such 
a degree of nervous irritation following it as to cause them to regard the 
approach of the male with absolute disgust and repugnance. The life 
of a woman of the latter class with an erotic man — a man who is so selfish 
as to care only for his own gratification — becomes a ''hell on earth." 
She considers herself a sexual slave, bound to a man whose only regard 
for her is as an instrument to minister to his passion. Whatever regard 
she formerly entertained for him soon becomes dissipated. Constant 
dwelling upon her sense of wrong and fretting against the bonds which 
envelop her, leads not only to the production of local disorders but to 
melancholia, hysteria, neurasthenia — even mental derangement. 

Equally disastrous is the union of a young erotic woman with an old 
and especially impotent man. 

Stimulation of eroticism by bad literature, by intimate association 
with the opposite sex, or by onanism, are prolific in the development of 
local disease. Long engagements, unless occasioned by separation, 
are prejudicial in that the frequent hyperemia produced by repeatedly 
awakened and unsatisfied longings causes chronic oophoritis. 

The most potent factor to-day in the production of pelvic disease 
is a result of efforts to avoid maternity. Nature has her revenge upon 
those who would violate her laws. When the natural result of the marital 
relation is avoided by withdrawl of the penis before the act is completed 
both parties to the act are injured. The incomplete discharge causes 
the man an irritation which produces a sensation of discomfort and unrest 
that leads to more frequent coition and consequent nervous exhaustion, 
or neurasthenia for both participants. The continuous engorgement 
without the salutary influence of the completed orgasm and the failure of 
impregnation produces a continued hyperemia which renders the soil 
favorable for the development of the various pelvic inflammations. The 
deliberate indulgence of the sexual appetite with the premeditated inten- 
tion of avoiding its legimate result, begets a lowered moral attitude to- 
ward the sexual relation. The woman who continually avoids the pos- 
sibility and responsibility of maternity becomes little more than her hus- 
band's mistress, indeed, it may be questioned whether she is regarded so 
highly. If her sexual appetite be strong and she resents the apparent 
neglect of her husband, it does not become a long step for her to become 
the mistress of another. A woman so lost to the purpose of the marital 
relation wiU not hesitate to employ, or have employed, agents for the 
arrest of pregnancy when it occurs in spite of the precautions observed. 
Abortions or repeated abortions necessarily induce disorders of the 
pelvic organs. Nature makes her provision for the evacuation of the 



ETIOLOGY. 6l 

Uterine contents when the fruit has matured and earher separation finds 
it unprepared to resume normal relations easily. Involution is less rapid 
and prone to be incomplete. Subinvolution, descent, displacements, 
chronic endometritis and metritis, periuterine inflammation, and tubal 
and ovarian diseases are consequences of such interference. The genital 
organs may become so crippled as to render subsequent conception im- 
possible, or so irritated as to render the uterus unable to supply the neces- 
sary nutrition to mature the implanted ovum and abortion becomes the 
habit. 

d. Traumatic Causes. The injuries to which the genital tract are 
subject may be accidental, the result of violent efforts at intercourse, 
incident to parturition, or the result of operative procedures. The acci- 
dental injuries are comparatively infrequent, and, while capable of pro- 
ducing cicatricial changes, are generally insignificant in their ultimate 
effects. Coition has produced laceration of the perineum, tearing oft' of a 
rigid and resisting hymen, tearing of the vagina, and the formation of 
rectovaginal fistula. The act of coition is most likely to produce severe 
injury in the very young or in the elderly virgin. The greater majority of 
injuries occur from lesions of parturition. These may involve the body 
of the uterus, the cervix, the vagina, perineum, or pelvic floor, and the 
adjacent viscera. The lesion may be in the nature of a tear in healthy tissue 
which, if kept free from infection, soon heals, leaving only a more or less 
well marked cicatricial band; or, as a result of long continued pressure 
or bruising, is followed by extensive sloughing and loss of tissue, which, 
if recovery occurs, must be attended by deformity. Lesions of the genital 
canal are favored by malformations of the bony and soft part of the pelvis; 
small and contracted genital canal; undersize or malposition of the fetus; 
rigid and unyielding r^uscular structure; an inordinate amount of fat in the 
maternal tissues; enfeebled muscular action and ineffective labor pains by 
which the tissues are subjected to long continued pressure between the 
bones of the fetal head and those of the pelvis; and the rash and unskilful 
employment of manual and instrumental manipulation. The prompt 
and skilful resort to assistance has greatly lessened the frequency of severe 
lesions. It is true lacerations of the cervix and pelvic floor may be rela- 
tively more frequent under early interference, but such lesions are easily 
repaired and produce far less serious consequences than the extensive 
destruction of tissue resulting from protracted labor. 

Any lesion of the pelvic floor becomes an avenue for the entrance of in- 
fection. Extensive lacerations of the cervix and pelvic floor interfere 
with the process of involution so that the organs are much longer in reach- 
ing the normal. This may be prevented by various sequelce. In lacera- 
tion of the cervix, in addition to subinvolution, the cervical lips are fre- 
quently separated. The posterior may undergo involution while the anterior 
becomes hyper trophied. Increased secretion occurs from the cervical 
glands or superficial inflammation may lead to stenosis of the gland ducts 
and distention of the Nabothian glands until the entire cervix has under- 
gone cystic degeneration. In some cases the torn surfaces may become 
cicatrized, filling up the angles of the tear with wedges of cicatricial 



62 GYNECOLOGY. 

tissue, in which the nerve tendrils are imprisoned and pinched, producing 
various reflex phenomena. Occasionally the pressure of the cervix against 
the posterior wall of the vagina will lead to turning of the lips, the posterior 
upward and the anterior downward, in which position they are held by 
indurated tissue within the injured surfaces. The resulting endocervicitis, 
thickened mucosa, and distended glands produce ectropion of the mucosa, 
which increases the separation of the lips. 

That this condition is an incentive to the occurrence of carcinoma of the 
cervix is made evident by the fact that this is most frequently found in the 
cervix and in the cervices of women who have given birth to one or more 
children. Laceration of the pelvic floor in slight degree lessens the support 
of the viscera, retards involution, and the combination of decreased sup- 
port and increased weight of the superimposed viscera promotes descent, 
displacement, and chronic inflammation. Laceration through the sphinc- 
ter leaves the intra-abdominal pressure unresisted and renders the patient 
unable to control the contents of the lower bowel. The seclusion en- 
forced by this condition not infrequently results in melancholia and 
mental disturbance. Fistulous openings between the genital canal and 
the adjacent viscera produce constant sofling of the patient's person with 
urine or feces, irritating the skin of vulva and thighs, and make her a 
source of distress to herself and her friends. 

The discussion of the traumatic causes of pelvic disorder is incomplete 
if some consideration be not given to those which result from operative 
procedure. They are mostly the result of want of skill, improper tech- 
nique, inexperience, and faulty judgment. No man should undertake 
pelvic surgery who has not had large opportunity for observation in diag- 
nosis, and a careful training in surgical technique. Every surgeon is sad- 
dened by seeing patients who had not been seriously ill prior to a cure ting, 
with conditions demanding sacrificial operations; women bemoaning the 
loss of ovaries, who from the history evidently did not require such a 
sacrifice; and patients with fistulae, hernia, adhesions, and intestinal con- 
strictions, living lives of misery and discomfort, when they could have 
been restored to health readily had their operators been better trained. 

e. Infective Causes. Inflammatory diseases of the pelvis are with 
extremely rare exceptions due to micro-organisms. Those which are 
most frequent in their baleful influence are the gonococcus, staphylococcus, 
pyogenes aureus, streptococcus, bacillus coli communis, and bacillus tuber- 
culosis. The retention of portions of tissue which are exposed to the 
atmospheric air through the introduction of the saprophites cause putre- 
faction and through the absorption of the resulting toxins develop high 
temperature. The condition is denominated sapremia as contradis- 
tinguished from the multiplication of septic germs which produces 
septicemia. 

The gonococcus is without question the most prolific source of infection 
and invades the vulvo-vaginal glands, vagina, cervix, body of the uterus, 
tubes, ovaries, and pelvic peritoneum. Its existence in a severe degree 
makes its cure uncertain. Certainly no case is cured in the sense of res- 
toration to normal relations, nor can we be certain that subsequent 



ETIOLOGY. 6s 



symptoms will be in the form of sequelae, for numerous cases occur dem- 
onstrating recurrence of the disease without opportunity for fresh in- 
fection. Such attacks burst forth following sexual excess, intemperance 
in eating or drinking, or after exposure, and have appeared when previous 
examinations of the secretions have demonstrated that the gonococcus 
was absent. Recent researches have seemed to demonstrate that gono- 
cocci lapse into forms indistinguishable from pus cells or leukocytes and 
return to their characteristic form when galvanized into activity by some 
irritation. Such an explanation accounts for reinfection in a previous 
victim and its transmission by him to others. 

The gonococcus renders the infected soil more favorable for the re- 
ception and nutrition of other micro-organisms. The simultaneous action 
of some other organism with the gonococcus is known as a mixed infection. 
The retention of decomposing products and the occurrence of sapremia is 
also favorable for the development of the graver forms resulting in 
sepsis. 

Infection from staphylococcus, or streptococcus, is always grave. 
Its progress depends upon the virulence of the infection and the vital re- 
sistance of the patient. It may become promptly localized or rapidly in- 
fect the blood and result in death. The bacillus coli communis is most 
likely to expend its baneful influence upon the peritoneum of the adjacent 
structures. The tubercle bacillus may affect any portion of the genito- 
urinary tract. Next to the lungs it probably invades the peritoneum most 
frequently. 

f. Causes Incidental to Age. The most superficial observation re- 
veals that the age of the woman renders her more susceptible to certain 
forms of disease. Some disorders are prone to occur at certain ages. 

The period prior to puberty is especially free from disorder. It is a 
period of quiescence, and yet we find the individual suffering from gonor- 
rheal infection which produces vulvo-vaginitis, a condition requiring 
prompt treatment to prevent its extension to the uterus and appendages, 
causing irrecoverable alterations. Ovarian growths occasionally mani- 
fest themselves during this period. With the advent of puberty the dis- 
orders multiply. Malformations render their existence recognizable by 
retention of menstruation; atresia in vagina or uterus; or imperforate 
hymen. A poorly developed uterus may be unable to perform its 
functions readily, so the patient suffers from dysmenorrhea and sterility. 
During the years of active menstrual life the chaste unmarried w^oman 
suffers from endometritis, oophoritis, the occurrence of myomata, and 
chronic inflammation of the ovary. Ovarian tumor and, occasionally, 
carcinoma may be manifested. In the virgin, the latter is more apt to 
affect the body. 

The married woman, while possibly slightly less susceptible to myo- 
mata, may undergo infection, producing endometritis, metritis, oophor- 
itis, salpingitis, and periuterine inflammation, either perimetritis or 
parametritis, or the two combined. She is prone to cervical carcinoma 
from the injuries the cervix receives during parturition. Such patients are 
more prone to infections from their greater exposure in the contingencies 



64 GYNECOLOGY. 

incident to the sexual relations, the possible interruption in the course of 
pregnancy, and increased exposure at the period of parturition. 

Carcinoma, while possible at any period, is apt to manifest itself at 
or near the menopause. Ovarian cystomata are more frequent during 
this period, but may occasionally develop before or after the period of 
menstrual life. Subsequent to the menopause carcinomata, prolapsus, 
and senile endometritis are the affections most frequently seen. 

DIAGNOSIS. 

23. Difficulties in study, demonstrated by our discussion of etiol- 
ogy, are no less marked when the student of gynecology essays correct 
diagnosis. Probably in no department of medicine are greater barriers 
interposed to its accomplishment. In the study of the diseases of women, 
much must depend upon proficiency of touch which is acquired only by 
extensive practice. The delicacy and power of this sense varies so greatly 
in different individuals that it is difficult to convey an adequate idea of the 
relative hardness or softness of the structures under observation. 

The ovaries and tubes in which important lesions occur are quite in- 
accessible in many patients to the ordinary methods of examination. 
Pathologic lesions, then, must often be the subject of inference or specu- 
lation, rather than capable of absolute demonstration. 

* To render the study of symptoms more difficult, the suggestion that 
she must subject herself to examination is repugnant to the modesty of 
every woman, and the disease exists in organs so sensitive that manipu- 
lation can not be repeated by a number of persons in succession. The 
patients who are willing to be brought before a class of students and sub- 
jected to such examination are exceedingly few, consequently many 
practitioners must enter upon their vocation with but little or no practical 
knowledge of the subject. 

24. The Cultivation of Habits of Close Observation is of the 
Utmost Importance. The observant physician generally will be able to 
determine with considerable accuracy the circumstances, condition, and 
state of disease in a patient from her conduct, manner and general appear- 
ance. Thus, a woman with an abdominal enlargement, if she appears 
well nourished and enters the physician's office with a face presenting the 
rosy hue of health, would naturally be suspected of suffering from a 
physiologic rather than a diseased condition, and would be pronounced 
pregnant; while a pale countenance, emaciated face, thin cheeks, and 
sunken eyes associated with such an enlargement would be regarded as 
indicating an ovarian growth. This special association of the features is 
known 2i^ fades ovariana, and is of value in forming the diagnosis. The 
conduct and deportment of the patient will frequently announce whether 
she is married or single; her manner of walking or sitting, the existence of 
a pelvic inflammation. 

25. Exercise of judgment will prevent those errors in diagnosis 
which are frequently the result of hasty conclusions founded upon in- 
sufficient investigation. Recognition of the existence of a lesion is at once 



DIAGNOSIS. 65 

accepted as an explanation for all distressing symptoms. An accurate 
diagnostician will not permit his judgment to be swerved by the reasoning 
of another; nor come to the investigation with preconceived conclusions; 
but will form his decision only after a careful and thorough examination 
of every organ capable of producing such symptoms. 

26. Value of Notes. The young physician should accustom him- 
self to taking notes of his office cases. He thus forms the habit of more 
careful and systematic investigation of every patient, accumulates data 
from which he is enabled to formulate more definitely judicious plans of 
treatment, and, probably most important of all, has the means of refreshing 
his mind from time to time as to the condition of any particular patient. 

27. History. The notes should record the name, residence, age, 
condition of patient, married or single, family history, personal history (as 
previous sickness, duration of present illness, supposed cause, progress, 
and symptoms). 

Menses: first appearance, regularity, duration, what changes have 
since occurred; present habit, date of last menstruation. 

Pain, whether it precedes, accompanies, or follows the periods, its 
character, severity, and where experienced. 

Leukorrhea: amount of discharge, duration, continuance, color, con- 
sistence, and effect upon the parts with which it comes in contact. 

Number of children or miscarriages: character of labor and con- 
valescence and the influence upon subsequent health. 

Coition: painful, sensation, frequency, methods employed to avoid con- 
ception. 

^ Interrogation of other organs: regularity of alvine dejections, frequency 
of micturition, digestion; pain in head, in lumbar region, in groins, down 
the limbs, etc. 

28. The 'subjective symptoms are elicited from the patient or her 
attendants. As already asserted, the difficulty experienced in determining 
the ph3^sical signs frequently makes these symptoms of great value. 
Every such symptom, however, must be weighed carefully, as both patient 
and attendants are prone to exaggerate its character and severity, or may 
err both in observation and interpretation. 

29. Causes of Error. Lisfranc writes: "By their almost latent 
state, their great variety of symptoms (often very transitory), their sym- 
pathetic effects on all parts of the economy, and their immense influence 
on the nervous system, uterine diseases are peculiarly apt to lead medical 
practitioners into errors of diagnosis." (Clinique Chirurgicale de la Pitie, 
vol. ii, p. 182, Paris, 1842.) 

The reason for these errors is the difficulty in understanding their 
cause. Uterine symptoms are not always the most prominent, are slowly 
developed, and do not always attract the attention of the patient. Not 
infrequently is the physician consulted for disorder of the stomach, of the 
heart, or of the liver; for vomiting, nausea, want of appetite, or diarrhea; 
for neuralgia or hysteria; for a train of evils having their origin in poverty 
of the blood, as chlorosis, anemia, emaciation, and exhaustion — all of 
which may be symptomatic manifestations of an obscure uterine malady. 
5 



66 GYNECOLOGY. 

The interrogation [should proceed so systematically from general to 
local symptoms as to impress the patient, upon its completion, that the 
only logical course is a physical investigation of her pelvic organs. 

30. General or constitutional symptoms may so predominate 
as to obscure the diagnosis wholly, and cause both patient and physician 
to believe that other than the pelvic organs are directly at fault. Com- 
plaint will be most frequently made of symptom's which may be denomi- 
nated as gastro-intestinal, such as gastralgia, nausea, vomiting, perverted 
appetite, anorexia, and regurgitation associated with a clean tongue. 
Nausea and obstinate vomiting are likely to be associated with ovarian 
disease. So are intestinal indigestion, indicated by gaseous distention, 
the formation and absorption of toxins which disturb the sleep, cause un- 
pleasant dreams, perverted nutrition and neurasthenia. Nervous anes- 
thesia affects portions of the lower extremities, as over the front of the 
thighs. It is especially prone to extend to and involve the clitoris, geni- 
tals and vagina, when all sexual desire and pleasurable sensation 
during coition become lost. This condition is particularly associated 
with retrouterine inflammation and chronic metritis complicating retro- 
displacement. 

31. Nervous Manifestations. The bladder and rectum are fre- 
quently the seat of burning, uneasiness, or spasms of pain, but such dis- 
turbances are not confined to them for remote organs are also affected, 
such as liver, stomach, intestinal canal, and heart. Patients not infre- 
quently suffer from symptoms which cause them to believe themselves the 
victims of serious disorder of the heart. These entirely disappear upon 
proper treatment directed to a pelvic lesion. 

Neuralgia in the lumbar and dorsal regions, — intercostal neuralgia of 
the left side, — leading the patient to fear the existence of organic heart 
disease, is common. The trifacial nerve may be involved, producing the 
sensation of a nail being driven into the head. Sympathetic pains are fre- 
quently noticed in the heart, with a sensation of swelling, especially 
marked during menstruation. I have often observed intense pain in the 
breast associated with a chronic inflammation of the corresponding ovary. 
The pain is usually ameliorated or absent during menstruation, but 
aggravated during the menstrual intervals. 

Motor and sensory paralysis is not an infrequent concomitant of uterine 
disorder. It is sometimes difficult to recognize its cause. Occasionally 
it is unquestionably due to hysteria, but numerous cases can be cited where 
the replacement of a retroverted uterus has resulted in the rapid restoration 
to health of patients who were apparently suffering from complete para- 
plegia. I have seen a patient in whom the incoordination of motion was 
so marked as to lead to the diagnosis of advanced locomotor ataxia 
recover without a vestige of the disorder subsequent to an amputation 
of a hypertrophied and inflamed cervix and the repair of a relaxed 
pelvic floor. 

32. Disorders of Nutrition. Every physician is famfliar with the 
profound influence upon the processes of nutrition frequently engendered 
by the occurrence of pregnancy. It does not seem unreasonable to antici- 



DIAGNOSIS. 67 

pate that the substitution of a pathologic lesion for a physiologic condition 
will exert equal if not greater disturbance of these processes and an im- 
proverished condition of health necessarily results. Doubtless the dis- 
turbed balance of the internal secretions has much to do with the produc- 
tion of such disturbances. The conditions w^hich most frequently occur are 
chlorosis, anemia, and general debility. 

Chlorosis is found in poorly nourished girls who suffer from it at 
puberty, or frequently in women during pregnancy. That it is often a 
result rather than a cause of pelvic disorder is made evident by the rapid 
improvement of the patient through the establishment of the menstrual 
function or the termination of a pregnancy. 

Anemia may occur at any age. In the earlier periods of life it may 
be both a consequence and cause of pelvic disease. It is especially 
associated with chronic inflammation of the uterus and appendages. It 
is marked in uterine myomata of the interstitial and submucous varieties, 
in the various forms of malignant disease, and in chronic inflammation of 
the urinary tract. Repeated and prolonged hemorrhages, continuous 
leukorrhea, loss of rest from pain, or from frequent micturition are contrib- 
uting causes. The condition is indicated by loss of color in the skin, 
transparency of the tissues, local edema, frequent weak pulse, and general 
debility. These disturbances of nutrition are accompanied not only by 
general debility, but also by progressive emaciation, until the disorder 
producing them has been corrected. Under the influence of the diseased 
condition the patient becomes prematurely aged. The head is stooped, 
the limbs are bent, the features are drawn, and she presents a look of 
suffering; the flesh is soft and flabby; the countenance is expressionless, 
the complexion pale and faded, especially when leukorrhea has been long 
continued and profuse. The paleness is different from that of ordinary 
anemia; it causes the characteristic appearance that has been recog- 
nized under the name of fades uterina (Courty). Emaciation may not 
always be present; on the contrary, the patient may sometimes be 
corpulent, particularly when amenorrhea, rather than leukorrhea or 
hemorrhage, occurs. The obesity is sometimes so great as to lead the 
patient to believe herself pregnant, and not infrequently, while suffering 
severely, she is congratulated by her acquaintances upon her excellent 
appearance. 

33. Local symptoms are those disturbances of function and dis- 
agreeable sensations which are directly traceable to the genital organs and 
the structures in immediate association with them. 

These symptoms comprise: discomfort in sitting, a sensation of weight 
and pressure in standing or walking, heat and burning in the vagina, pain 
upon movement, tenderness to pressure over the abdomen, frequent and 
painful micturition, more or less profuse discharge, absent, too frequent^ 
irregular, and painful menstruation, pain during the act of coition or even 
upon touching the vulva, and a sensation of distress and aching following 
the sexual relation. Reflex phenomena from the rectum or bladder, or, 
on the other hand, sympathetic irritation of the uterus, when either of the 
former organs is the seat of disease, are very common, and the frequency of 



68 GYNECOLOGY. 

their occurrence can be appreciated when we remember that the nerve, 
supply to the uterus, rectum, and vagina is derived from the cervico- 
uterine ganglia of the hypogastric plexus. 

34. Rectal Reflexes. It is not unusual to find that during men- 
struation women suffer from diarrhea, proctitis, and rectal tenesmus. 
The pelvic vascular system is so general that engorgement or inflammation 
of the uterus will not fail to produce congestion in the other pelvic organs; 
and in any marked inflammation of the organ, associated with displace- 
ment, and particularly in retrodisplacements, the hemorrhoidal vessels 
will be found to be distended; thus, hemorrhoids in the female very fre- 
quently result from retrodisplacements of the uterus, and never should be 
subjected to operative treatment until the displacement has been corrected. 
In anteversion the cervix will frequently be found to project against the 
anterior wall of the rectum, and can be readily distinguished through this 
viscus. When the cervix is inflamed, the impingement of hard fecal 
matter against the organ not infrequently causes severe pain. In some 
cases this pain is experienced only during menstruation. The most fre- 
quent functional disorder of the rectum is constipation; partly from neglect, 
and partly from want of nerve irritation, the bowel becomes filled with 
fecal matter, the watery portions are absorbed, and hard, dense, scybalous 
masses form, which are evacuated with difficulty, and possibly only after 
repeated enemata. The muscular coat of the bowel becomes distended, 
loses its 'tone, and results in a form of paralysis; fecal matter undergoes 
decomposition, is pardy reabsorbed, and causes the condition which 
Barnes has denominated as copremia, in which the skin is of a sallow, 
dirty hue, the breath and emanations from the skin, foul; the patient 
suffers from dyspepsia, flatulence, and pyrosis — a condition akin to that 
known as uremia. The violent efforts to evacuate the bowels not only 
lead to the formation of hemorrhoids, fissure, sometimes fistula, but, 
through the increased intraabdominal pressure they may cause displace- 
ment of the uterus and the vagina. When fissures exist, the pain during 
defecation is so great that the patient is likely to permit the bowels to go 
unevacuated rather than endure the resultant pain. 

35. Vesical Reflexes. The relation of the bladder to the uterus is 
more intimate than that of the rectum, and consequently this organ is 
much more likely to sympathize with inflammatory conditions of the uterus. 
Retention of the urine may be produced by pregnancy or by pelvic growths, 
such as fibroid tumors or tumors of the ovaries. Sometimes as a result of 
irritation of the orifice of the vagina, a condition known as vaginismus 
occurs. The pain may be so great as to produce a spasmodic contraction 
of the sphincter of the bladder. The most usual functional derange- 
ment of the bladder, however, is frequent micturition. It may occur as the 
result of reflex irritation from the pelvic organs, or in consequence of pres- 
sure from the uterus produced by the presence of a tumor or by a preg- 
nant uterus, or a displaced organ in which either the fundus rests forward 
upon the bladder or is turned backward, causing the cervix to press against 
the latter. Either of these conditions may lead to functional derangement 
of the bladder, so marked as to cause the patient to suspect the existence of 



DIAGNOSIS. 69 

disease of that organ, or, as she will more probably say, disease of the 
kidneys. 

36. Genital symptoms, attributable to the genital organs, are 
derangements in the performance of their functions. The particular 
symptoms are disturbances of menstruation, such as a decreased, increased, 
or irregular menstrual flow; the existence of sterility; the presence of pain 
and excessive discharge. Consequently, in determining the history of 
the patient, if she is married we endeavor to elicit information regarding 
previous pregnancies and the character of the labors. Sterility in a woman 
who has been married for a number of years is an indication of some ab- 
normal condition. It may be due to a malformation, functional disturb- 
ances, actual disease, or efforts to avoid the responsibility of maternity. 
It should be remembered, however, that there are cases of relative sterility 
and that the male alone may be responsible for the failure to procreate. 
The most unvarying function of the uterus is that of menstruation, con- 
sequently some disturbance in the performance of this function is one of the 
first indications of the existence of uterine disorder. Amenorrhea is a 
term employed to designate absent or greatly decreased menstrual flow; 
Menorrhagia the flow, which though regular is increased or prolonged; 
metrorrhagia, a discharge of blood, often a hemorrhage which bears no 
relation to the normal period; while dysmenorrhea indicates the existence 
of pain occurring at the beginning of, during, or immediately following the 
menses. The conditions will be considered more fully later. (See Func- 
tional Disorders.) 

37. Hemorrhage is by no means a constant symptom of uterine 
disease. Its significance varies according to the amount of blood lost and 
the time of life at which it occurs. During the earlier periods of men- 
strual life it is not uncommon for the menses to be profuse, as a result of in- 
sufficient or overabundant production of the internal secretion of the 
ovary. When hemorrhage occurs in women who have borne children, it 
may be produced by inflammation of the mucous membrane of the uterus 
— hence a hemorrhagic endometritis. Hemorrhage is a usual symptom of 
fibroid growths of the submucous variety. Uterine polypi, whether due to 
a fibroid growth or to vascular growths upon the endometrium, are a very 
prolific cause near the climacteric. The occurrence of hemorrhage near or 
subsequent to the menopause should always cause the physician to suspect 
the possibility of malignant disease in either the mucous membrane of the 
cervix or the body of the uterus. When hemorrhage occurs during or 
following pregnancy, it is probably due either to a threatened abortion or 
to retention of portions of the fetal envelopes. It should not be forgotten, 
however, that hemorrhage may occur from cystic disease of the ovaries, 
and in any condition affecting the vascular tension, even though no pelvic 
lesion is apparent, as in valvular disease of the heart, Bright's disease, and 
obstruction of the portal circulation of the liver. The occurrence of hem- 
orrhage should always be regarded as an important danger signal de- 
manding careful investigation to determine the cause. 

38. Pain is a very frequent symptom and may be associated with the 
menstrual function, when it is known as dysmenorrhea, or may be in- 



70 GYNECOLOGY. 

dependent of it. When it occurs during coition, it is called dyspareunia 
(Barnes). It may be dependent upon, first, vaginismus; second, chronic 
nervous irritability due to incomplete or awkwardly performed first 
coitus; third, inflammation; fourth, tumors; and fifth, malformations. 

Courty describes six seats of pain, three of which are principal and three 
accessory. The principal seats are: i, the iliac regions; 2, the loins; and 
3, the hypogastrium. 

Iliac pain is the most frequent. It is felt in the iliac fossa, from which 
it extends to the hypogastric and lumbar regions, particularly toward the 
pelvic brim and cavity. It is most often felt upon the left side and is due, 
probably, to tension of the broad ligament occurring more frequently 
upon the left side because of the arrangement of the venous circulation. 
The left ovarian vein enters the left renal at a right angle, and passes be- 
hind the sigmoid flexure of the colon to reach it. The frequent impaction 
of this portion of the gut with feces accounts for the obstructed circulation. 

Courty ascribes the pain in this region, however, to the inclination of 
the uterus to the right; hence, any increase in its size causes a dragging 
upon the left broad ligament. 

Lumbar pain, generally spoken of as backache, is felt in the lower 
part of the lumbar region, sometimes extends over the kidneys, or, more 
frequently, down over the sacrum. Occasionally the abdomen is en- 
circled as with a belt of pain. This pain is usually ascribed to traction of 
the utero-sacral ligaments. Doubtless it is frequently due to retention of 
secretion within the uterine cavity, by which the organ is obliged to go 
into labor to secure its expulsion. Pain particularly marked in the sacrum 
indicates disease of the cervix and is doubtless caused by retrodisplace- 
ment of the uterus. 

Hypogastric pain is felt above the pubes and most probably has its 
origin in the uterus. It is artificially elicited rather than occurring spon- 
taneously. Even patients who do not ordinarily experience it, complain 
as soon as pressure is made over the lower portion of the abdomen. 
This pain is greatly aggravated by walking, so that the patient frequently 
feels the necessity for support over the hypogastrium by means of a belt or 
by placing the hands in front, partly for support and partly for protection 
against injury. 

The accessory seats of pain described by Courty are found: i, in the 
anus or perineum; 2, in the vagina or cervix; and 3, in the cavity of the 
pelvis. 

Anal or perineal pain is usually produced by a retrouterine tumor or 
retroflexed uterus. A patient with a hypertrophied or inflamed cervix 
will frequently suffer pain in the anus or perineum while walking or riding, 
and often when sitting. 

Vaginal pain is more rare. It is felt particularly during an orgasm 
by women who have inflamed uteri. 

Pelvic pain results usually from inflammation about the uterus or 
tubes, fixation of the ovaries, or when organs have become cystic or the 
seat of pus collections. 

39. Leukorrhea, or whites, is a term given to discharges, other than 



DIAGNOSIS, 71 

sanguineous, that occur from the genital tract. To appreciate the sig- 
nificance of a discharge as an indication of disease, we must recognize the 
character of the normal or physiologic secretion. 

The secretion from the Fallopian tubes and cavity of the uterus is a thin, 
whitish, alkaline fluid, while that from the cervical glands, also alkaline, is 
very viscid, tenacious, and transparent like white of egg. 

The secretion of the vagina and vulva is whitish, made up of a serous 
fluid, mixed with scaly epithelium. The \nilvar discharge also contains 
oil globules from the sebaceous glands. The secretion of both vagina and 
vulva is acid. 

The superfluous discharge from the cervix is coagulated by that of the 
vagina, forming a smeary material at the upper part of the vagina, which 
will be found to coat over the surface of a pessary. When the cervical 
fluid is in excess, it may pass from the vagina unchanged and perfectly 
transparent. 

Another discharge or secretion takes place from the vulvovaginal 
glands during coition or under excitement. This is clear and viscid. 
In very erotic women this discharge is ejected upon the approach of a 
person of the opposite sex, and nocturnal discharges occur during erotic 
dreams. 

It is sometimes difficult to determine whether a discharge is the result 
of over-stimulation of a physiologic secretion, or is produced by a patho- 
logic condition. A profuse discharge is not an infrequent result of ex- 
posure to cold. An increased secretion from the uterine glands occurs 
instead of the ordinary nasal flow. A hypersecretion resulting from hy- 
peremia of the pregnant uterus may be considered physiologic. In un- 
developed and strumous young women a leukorrhea often occurs as a 
substitute for the menses. In many individuals a slight leukorrhea pre- 
ceding or following the menses has no abnormal significance. 

The origin of the abnormal discharge generally can be determined by 
its appearance and character. When from the cavity of the uterus, it will 
be thin, watery fluid, loaded with ciliated columnar epithelium, and con- 
taining also pus and blood-corpuscles, according to the extent of the dis- 
ease. The discharge may be a continuous flow. More frequently it is 
intermittent, due to defective drainage from swelling of the mucous 
membrane of the outlet, which leads to dilatation of the cavity and not in- 
frequently of the orifices of the tubes. The uterus then empties itself by 
occasionally going into labor to evacuate its contents. Such a fluid, loaded 
with pus and blood-corpuscles, coming away in gushes, leads the patient 
to believe that an abscess has formed and been evacuated. Patients will 
assert that they have abscesses form and discharge at short intervals. 
The conditions described, however, may not be the only solution. An 
accumulation in a tube, the uterine end of which is still patulous, may 
drain at intervals through the uterus. Such a condition has been de- 
nominated hydrops tiibce profliiens. 

Other sources of purnlent discharges are found in the rupture and escape 
into the vagina of the contents of a tubal or peritoneal abscess; of a sup- 
purating ovarian tumor; of an extrauterine pregnancy sac; or of an abscess 



72 GYNECOLOGY. 

about the vermiform appendix. The discharge from the cervix is usually 
viscid and tenacious. It may be clear and transparent or clouded by 
desquamated epithelium and filled with pus-cells, when it is yellowish or 
greenish-yellow in color, or it may be a dirty brown from admixture with 
blood-corpuscles. 

The cervix will usually be dilated and patulous, its membrane thickened, 
abraded, and covered with papillae. The discharge from vulva and 
vagina, is thin and serous and resembles that from eczema. After pub- 
erty, in the unmarried, it is generally vaginal. In the more mature and 
in married women it is usually uterine. 

As the individual approaches puberty the vulvar discharge becomes 
oleaginous from the secretion of the sebaceous follicles. In uncleanly 
persons the secretion from these glands is so abundant that it often accu- 
mulates between the large and small labia, decomposes and sets up an in- 
flammation similar to the blennorrhea of the male. Prior to or following 
the climacteric a thin, watery flow, of a sweetish, sickening, or decayed 
flesh-like odor, should be considered a strong indication of cancer of the 
uterus. 

40. Physical Signs. Careful study and analysis of the subjective 
phenomena may afford an approximate idea of the disorder present, but 
the diagnosis should not be attempted until the objective symptoms or 
physical signs have been investigated. 

The physical signs are determined by employment of all the senses 
except that of taste. 

Sight is employed in the inspection of the abdomen and external geni- 
talia and in examining the internal organs by use of the speculum. 

Touch is practised in abdominal palpation and percussion, in simple 
vaginal or rectal touch, in conjoined manipulation, and in the use of the 
sound or catheter. 

Hearing is employed in percussion and auscultation. 

Smell is exercised in the examination of discharges. 

41. Examination may be made through the vagina, rectum or 
urethra, or a combination of one or more of these with pressure over the 
abdomen. The examination may be pelvic or abdominal (although in 
practice it is preferable to combine the two) and consists of inspection, 
palpation, percussion, auscultation, combined palpation, instrumental 
investigation and exploratory puncture or incision. 

42. Positions. The patient may be placed in one of six positions 
for examination: i, dorsal; 2, lateral; 3, semiprone (Sims') ; 4, genupectoral; 
5, Trendelenburg; and 6, erect. Of these positions the dorsal and the 
Trendelenburg are the most important. 

I. The Dorsal Position. (Fig. 46.) The patient lies upon her back, 
with the limbs flexed and feet placed upon supports. The feet may be 
on a level with the buttocks or placed on supports a foot higher. This 
affords greater relaxation to the abdominal muscles. The clothing is 
lifted over the knees. The lower part of the body has been previously 
covered with a sheet folded about the widely separated limbs. This 
position permits inspection of the vulva, and the ready practice of 



DIAGNOSIS. 



73 



bimanual examination. It is the most favorable for vaginal and abdom- 
inal palpation and use of the valvular and Edebohl's specula. For 
operative procedure the dorsal position may be favorably modified by 
flexing the legs strongly upon the body, in which posture they may be 
retained by assistants or the employment of a suitable leg holder. This 
is known as the lithotomy position. 

2. The Lateral Position. The patient lies upon the left side, with the 
limbs at a right angle to the body. This position was formerly much 
used by English gynecologists, and was preferred because it permitted 
examination to be made without danger of touching the tender structures 
at the anterior part of the vulva. This position was thought less vulgar, 
and it allowed the finger to follow more readily the curve of the sacrum 
and to reach with greater ease the highly situated cervix. Its chief 
advantage, however, is in permitting more minute investigation of the 
lateral fornices of the vagina. In 

abdominal palpation it affords in- 
creased opportunity of recogniz- 
ing changes of position of tumors 
and displacements of the viscera, 
particularly of the kidney. 

3. TheSemiprone orSims^ Posi- 
tion, (Fig. 47.) The patient is 
placed upon the left side and chest, 
with the left arm behind her, the 
left leg partly extended, the right 
being flexed at a right angle to the 
body. The intra-abdominal pres- 
sure is neutralized. The mobility 
of the uterus is readily determined, 
replacement more easily accom- 
plished, and some anteflexions rec- 
ognized as the organ falls for- 
ward that are not apparent in any 
other position. The chief value 
of the position is in the use of the 
Sims' speculum. 

4. The genupectoral position (Fig. 48), also called the knee-chest 
position, is one in which the patient rests upon the chest and knees. The 
left side of her face rests upon her left hand. The thighs are at right 
angles. to the surface of the table. The chief value of this position is in 
replacing a retrodisplaced uterus or prolapsed ovary, or for elevating 
from the pelvis a more or less impacted tumor. 

5. The Trendelenburg Position. The patient lies upon her back on 
a plane inclined at an angle of 45 to 60 degrees, with the feet and legs 
over a flap of the table (Fig. 49). Heavy patients should have additional 
support by the application of shoulder pieces. Pryor modified the posi- 
tion by supporting the patient from the shoulders and flexed the legs upon 
the body for the purpose of examination of the pelvic viscera free from the 




Fig. 46. — Dorsal Position. 



74 



GYNECOLOGY. 



intestines, which gravitate upward when free to do so. This posture is 
of especial value in cystoscopic investigation of the bladder. The great- 
est value of the Trendelenburg posture is in the freedom of view afforded 




4 



Fig. 47. — Sim's Position. Proper Method of Holding the Speculum. 

in abdominal section, permitting the operator to employ the sight as well 
as touch. 

6. The erect position is of limited application. The patient stands 




Fig. 48. — Genupectoral Position. Organs Shown in Outline. 

with feet separated, with one hand resting upon the shoulder of the 
physician, while he sits or kneels before her and introduces the index- 
finger into the vagina. The chief value of this position is in determining 



DL4GN0SIS. 



75 



the amount of downward displacement of the pelvic contents and in secur- 
ing ballottement in the early stages of pregnancy. 

43. Preliminaries. The verbal examination having been so con- 
ducted that, when it is completed, the patient will be impressed with the 
fact that a physical examination is the only logical course, the examination 
may be made on a sofa or common bed, as would be the custom when 
made at the home of the patient. In office practice, however, it will be 




Fig. 49. — Trendelenburg Position. 



found more convenient to provide a suitable table or chair. The choice 
of table will depend upon the custom and convenience of the operator. 
One made by Codman & Shurtleff, of Boston, known as the Chadwick 
table, is very satisfactory. (Fig. 50.) In the first examination for 
the consideration of obscure conditions the clothing should be loosened 
and corsets removed, so that the abdominal walls can be completely 
relaxed. The bladder and rectum should be empty. The latter sug 



76 



GYNECOLOGY. 




Fig. 50. — Chadwick Table. 



gestions are very important in order to permit the normal relations of the 
uterus and its adnexa to be determined. Fecal accumulations have been 
mistaken for ovarian and tubal enlargements or inflammatory exudates. 
A distended bladder has been confounded with an ovarian tumor. 

The abdomen of every woman applying for first examination should 
be exposed from the symphysis to the diaphragm. This is accomplished 
by covering the lower extremities with a sheet which is drawn over the 
symphysis while the clothing is pulled upward. Constricting clothing 
should be so loosened that, when desirable, the mammae also may be 
inspected and palpated. Such an examination permits the recognition 

of changes in the mammary gland, 
ptoses of the abdominal viscera, 
tumors, hernia, gall-bladder and 
appendiceal disease, which would 
otherwise be overlooked. 

44. Inspection of the Abdo- 
men. An inspection of the exter- 
nal surface of the abdomen is of 
great value. The linea nigra, linea 
striata, and increase of pigment 
about the umbilicus and lower 
abdomen are signs indicative of a 
previous or present pregnancy. 
These discolorations having once 
occurred are never effaced, and are consequently of significance only 
during a first pregnancy. The linea striata are red or purple, when 
recent; white and glistening, when old. They are caused by over- 
stretching of the skin, hence may result from any abdominal enlarge 
ment. Discolorations from blisters and counterirritants or scars from 
leech bites and wet-cups are indications of previous inflammation. 
The superficial abdominal veins are enlarged by any pressure upon the 
deeper vessels, and the enlargement occurs in pregnancy, in fibroid, ova- 
rian, and other large tumors. The subcutaneous tissues become edema- 
tous in general dropsy and from acute abdominal inflammation. The 
association of enlargement with the affected viscera is more readily effected 
by dividing the surface into quadrants, by vertical and transverse lines 
crossing at the umbilicus. (Fig. 52.) The abdominal enlargement 
may be symmetrical, irregular or nodular; the abdomen flattened and 
broadened in ascites, or narrowed and projecting in pregnancy, myomata 
and ovarian cysts. The tumor may be spheric, most prominent above 
to the right in pregnancy, rise abruptly, attaining its greatest prominence 
near the umbilicus in ovarian cystomata, but is less likely to be symmetric 
in myomata. The surface of the skin is smooth and glistening from 
internal enlargement, and hangs in folds over the symphysis in obesity. 
A dependent mass may be due to the protrusion of a large tumor between 
the separated recti muscles, or to a desmoid tumor of the abdominal 
walls. A large projection from the median line may be caused by a 
ventral hernia. Fetal movements, contraction of muscles, and peristaltic 



DIAGNOSIS. 



77 



action of the intestines often can be seen. Enlargements in the upper 
right quadrant of the abdomen are due to growths in the Hver, distention 
of the gall-bladder, enlargement of the right kidney, or malignant disease 
of the ascending or transverse colon. In the median line, the liver, 
stomach, pancreas or transverse colon may be the seat. Above in the 
left quadrant, the spleen, the left lobe of the liver, the cardiac end of the 
stomach, or the left kidney may cause enlargement; and below, the 
descending colon. Ptosis of the stomach and liver frequently can be 
recognized. In the lower abdomen, the genital organs are the seat of 
the majority of abnormal growths. A tumor in the right lower quadrant 
should always awaken a suspicion of appendiceal inflammation or malig- 
nant disease of the colon. 




Fig. 51. — Abdomen Prepared for Examination. 

45. Palpation may be practised during inspection and consists of 
placing the hands, previously warmed, upon the bare abdomen and 
gently moving them from side to side, now close together, or again bring- 
ing the entire abdomen between their grasp. The tips of the fingers 
or the entire hand may be applied. Palpation enables us to recognize the 
thickness of the abdominal walls,- the presence of an abnormal growth, 
its situation, density, mobility and relation to the abdominal viscera. 
Its dimensions, smoothness or irregularity are recognized by carefully 
outlining the tumor. The relations and mobility of the tumor are deter- 
mined by changing the position of the patient or forcibly moving the tumor. 

The patient should lie on her back with the limbs flexed and the head 
and shoulders slightly elevated. Her confidence and cooperation must 



78 



GYNECOLOGY. 



be obtained in order to secure muscular relaxation. It is necessary to 
proceed with the utmost consideration and gentleness, as rough, hasty 
and inconsiderate palpation causes muscular rigidity and defeats its 
object. Pelvic abnormalities may require vaginal touch in conjunc- 
tion with palpation. This will be discussed under bimanual exami- 
nation. (§50). 

The examination may be made difficult by a large deposit of fat in the 
abdominal walls or the rigidity of the muscles from fear or actual tender- 
ness. Generally this can be overcome by 
reassuring the patient. In inflammatory 

t^^ collections great care must be taken to pre- 

,}^m vent the rupture of the growth and the 

'^B escape of its contents into the peritoneal 

46. Percussion may take place as a 
part of the two preceding steps, and consists 
— jj^ eliciting resonance or dulness by mediate 

or immediate percussion. Fluctuation is 
recognized by placing a hand upon one side 
and striking upon the abdomen, more or less 
^ remotely, with the finger-tips of the other. 
lif A long wave indicates that the fluid is 

free or contained in a large sac. A short 
or indistinct wave is produced by fluid con- 
tained in a sac with numerous partitions 
or septa. The chief value of percussion is 
in determining solid or fluid tumors from 
distentions of the abdomen by gas or ascites. 
The ability to elicit resonance and dulness is utilized in the diagnosis 
between free fluid within the abdomen and that contained within a cyst. 
In the former a zone of resonance is elicited over the summit of the disten- 
tion, while the remainder of the surface will be dull. This zone of resonance 
changes with the position of the patient. In a cyst the dulness is over 
its surface while the resonance is above and generally upon one side. 
Here the relative outline of the zones of resonance and dulness is not 
affected by change of position. The solid or cystic tumor, as it increases 
in size, pushes the viscera upward and to the opposite side; hence the 
situation of the zone of resonance. Resonance at the summit of the swell- 
ing in ascites is due to gas in the intestines which floats them to the surface. 
Should the mesentery be too short to reach the surface, from inflammation 
or great abdominal distention, percussion gives dulness; while deep 
pressure displacing the intervening layer of fluid again affords resonance. 
In localized peritoneal accumulations, percussion aids only in defining 
their boundaries, and presents the sensation of fluctuation. 

47. Auscultation is practised directly by placing the ear over the 
abdomen, with a towel or sheet intervening; and, indirectly, through the 
medium of a stethoscope. The former enables the physician to find the 
sound rapidly, the latter to study it minutely. Auscultation is of limited 




Fig. 



DIAGNOSIS. 79 

application. It enables us to hear the fetal heart-sounds, the bruit 
produced by the rush of blood through the uterine sinuses, and various 
sounds induced by gas and liquids in the intestines. The fetal heart- 
sounds are characteristic of pregnancy; the bruit is heard in pregnancy 
and fibroid tumors alike. Efforts have been made to diagnose the seat 
of intestinal obstruction by the gurgling noise in the intestines, but our 
knowledge of the normal sounds is not sufficiently definite to enable us 
to make it of much value. 

DIAGNOSIS: DIGITAL EXAMmATION. 

48. Examination of the Pelvis. Passing from the examination 
of the abdomen to that of the pelvis, the sheet is draped about the limbs 
of the patient to expose the vulva. This permits the condition of the 
external organs to be seen without shocking the sensibilities of the most 
modest. Information is secured as to cleanliness; the presence of pediculi; 
venereal warts or sores; malformations; traumatisms; vulvar eruptions; 
tumors; elongation and thickening of the labia minora; hypertrophy of the 
clitoris; elongated or adherent prepuce; lacerations of the perineum; 
the presence of hemorrhoids, anal ulcerations or fissures; urethral car- 
uncle; anomalies of the hymen; cystocele, rectocele; prolapse of the uterus; 
and the quantity and character of the vaginal discharge. This informa- 
tion through the eye is secured during the digital examination. 

49. Digital examination or simple touch is practised through one 
or all of the three apertures or perforations of the pelvic floor, the 
urethra, the vagina and the anus. The vagina is preferred usually as it 
affords the most extended information. 

The physician should cleanse his hands carefully. If she does not 
fear the possible danger of conveyed infection, the educated woman will 
be doubtful when her attendant proceeds to the examination with un- 
clean hands or nails. The latter should be cut close. Either hand 
may be used. Occasionally it may be desirable to use first one and then 
the other. In a roomy vagina two fingers should be introduced, as thus 
additional length and surface for touch is secured. The fingers should 
be lubricated with soap or an unguent like carbolized alboline. The 
soap is preferable, for in washing it is removed with the secretions. In 
some patients, however, it aggravates any existing irritation. With one 
hand the physician separates the vulva in order to avoid carrying up the 
hair, and holds the labia separated as he proceeds to make the digital 
examination. Pressing back the perineum, the finger or fingers enter 
easily without impinging against the delicate anterior structures. Depres- 
sion of the perineum with the index finger while the middle finger is 
inserted over it permits the employment of two fingers with little discom- 
fort. The unemployed fingers of the hand can be carried back, either 
extended or closed, but the latter shortens the distance accessible to touch. 
(Fig. 53.) Touch affords information as to the presence of cysts in the 
labia, size of the vagina, relaxation of its walls, condition of its mucous 
membrane, amount of secretion; tenderness and distention of the rectum; 



8o GYNECOLOGY. 

inflammation and projection of the urethra; tenderness, prolapse and 
distention of the bladder; and the relation of the uterus to the vaginal 
axis. Normally, the cervix looks backward, the axis of the uterus being 
nearly at right angles to the vagina. The situation, size, and density 
of the cervix are recognized. It may be normal, lacerated on one or both 
sides, or present a number of fissures — a stellate laceration. Its lips 
may be soft and velvety, from enlarged papillae; nodular, from enlarged 
or cystic Nabothian glands; widely everted and dense, from chronic 
inflammation following laceration; enlarged and indurated, from chronic 
inflammation or malignant infiltration; enlarged, friable, or excavated 
in epithelioma. The os will be a slightly transverse depressed dimple 
when normal. If abnormal, it may be fissured laterally, bilaterally, 



Fig. 53. — Proper Position of Fingers for Examination. 

through the anterior or posterior lip, or in a number of directions. It 
may be closed firmly, or stand open to such a degree as to admit the 
finger. The spaces about the vaginal projection of thq uterus are known 
as the fornices. The posterior fornix is the deeper; the anterior is slight. 
The resistance and density recognized indicate the existence or absence 
of inflammation. A mass felt in the posterior fornix, if continuous with 
the cervix, whose axis is parallel to that of the vagina, is a retroversion 
of the uterus. If there is an angle between the mass and the cervix, 
the condition may be a retroflexion of the uterus, a tumor of the pos- 
terior uterine wall, an enlarged ovary or tube, or an inflammatory 
exudate. Digital examination also affords an idea of the mobility of 
the uterus, but the investigation is confined to its lower segment. 

50. Bimanual procedure, also called conjoined manipulation, or 
vagino-abdominal touch, affords definite information. In every exam- 



DIAGNOSIS. 



ination the introduction of one or two fingers into the vagina should be 
associated with the application of the fingers of the other hand upon the 
abdomen. The external hand may be placed about midway between 
the symphysis and umbilicus, pressing downward upon the anterior 




Fig. 54. — Half Section of the Pelvis with Patient Erect, Showing Xormal Position of the 

Uterus. [Deaver.) 



abdominal wall. It may be moved from one side to the other, in order 
to examine the contents of the pelvis. This procedure enables us to 
outline the size, shape, density, and situation of the uterus, and to deter- 
mine the presence of growths in its walls and its relation to other pelvic 
growths or to inflammatory deposits. The normal tube is rarely palpa- 
6 



82 



GYNECOLOGY. 



ble. When it is readily perceived, it has been the seat of an inflammatory 
condition. The ovaries are more easily recognized. To arrive at a 
definite conclusion in an obscure case, it is better to introduce into the 
vagina one or two fingers of the hand corresponding to the ovary to be 
palpated, as the extreme rotation necessary to bring the sensitive surface 
of the finger in contact with a small mass diminishes the sense of percep- 
tion (Fig. 55.)^ 

The examination is rendered difficult when the abdominal wall con- 
tains a large deposit of fat, or the muscles are rigid. The rigidity is 




Fig. 55. — Bimanual Examination. 

sometimes so marked that determination of the pelvic condition is un- 
satisfactory. When due to nervousness, much can be accomplished 
by allaying the patient's fears and securing her cooperation. She should 
be directed to breathe with the mouth open and to sigh deeply, while the 
external hand depresses the wall during expiration, thus outlining the 
pelvic organs. Often by diverting the patient's attention through in- 
quiries regarding other symptoms, the difficulty is overcome. When the 
nervousness is persistent, or the sensitiveness arises from an inflammatory 
condition, or the abdominal walls are very thick and fat, an anesthetic 
may be required. 



DIAGNOSIS. 



83 



The examination of a young unmarried woman often presents a 
serious question. It should be avoided unless the symptoms indicate the 
existence of conditions which endanger her health. The regular oc- 
currence of menstrual moHmina without bloody discharge after an age 
when puberty should be expected must be considered an indication for 
physical examination. Where a digital examination is demanded and 
the hymen is unruptured, the finger can be inserted into the rectum. If 
a vaginal examination seems indispensable, the discomfort can be lessened 
by lubricating the examining finger carefully and directing the patient 
to bear down during its introduction. 




Fig. 56. — Recto-abdominal Palpation. 



51. Rectal touch is known as the recto-abdominal, recto- vagino- 
abdominal, or recto-vesical touch. (Figs. 56, 57, and 58.) The routine 
practice of digital examination by the rectum in the first investiga- 
tion of a patient is to be recommended. The finger should be washed 
carefully after its removal from the vagina and before its introduction 
into the rectum, and vice versa. Neglect of this precaution may cause 
a severe proctitis from the introduction of infectious material. The 
anointed finger, first directed forward, and after its entrance carried 
backward is gently rotated. The examiner is enabled to recognize the 
condition of the rectum, the presence of fissures, hemorrhoids, ulcer- 
ations, contractions of the sphincter, sensitiveness of the coccyx, encroach- 



84 



GYNECOLOGY. 



ment upon the bowel by the uterus, the condition of the posterior surface 
of the latter organ, the presence of inflammatory exudate in the pelvis, 
malignant infiltration of the broad ligaments or peritoneum, and the 
position of the uterus, when it is desired to avoid vaginal examination of 
a virgin. 

The rectal procedure promotes replacement of a displaced uterus. 
The correction of malpositions is facilitated by the introduction of the 
middle finger into the rectum and of the index finger or thumb into the 











..^'^ 



A '"/ 



Fig. 57. — Recto-vagino-abdominal Palpation. Index-finger of one hand in the rectum, 
thumb in the vagina, and the fingers of the other hand over the abdomen. 



vagina. The conjoined rectal manipulation is known as the recto- 
abdominal, the recto-vagino-abdominal, or the recto-vesical, according 
to the position of the finger of the two hands. The absence or presence 
of the uterus in congenital atresia vaginalis may be determined by recto- 
vesical touch; that is, the introduction into the rectum of the finger and 
of a sound, bougie, catheter or finger of the other hand through the urethra. 
It is rarely necessary to explore the bladder with the finger. Simon 
introduced the whole hand into the bowel, thus securing additional 



DIAGNOSIS. 85 

information as to the condition of the pelvic organs. However, the 
serious injuries resulting from its practice render it an unjustifiable pro- 
cedure unless the surgeon has an exceedingly small hand. 

The rectal mucosa may be exposed by the insertion of one or two 
fingers into the vagina and pressing downward upon its posterior wall. 

Ferguson advises exploration of the abdominal viscera through an 
incision in the posterior vaginal fornix as preferable to an exploratory 
abdominal incision. It is true that such an investigation can be made 
and that it avoids the prolonged convalescence from an external incision, 
yet its practice will often result in a weakened pelvic floor which will 
subsequently prove an ineffective barrier to vaginal hernia. 

The subject of bimanual examination should not be dismissed with- 
out a word of caution. Severe pressure over the abdomen exaggerates 
any displacement and may cause one to be simulated which does not 
exist in ordinary conditions. It should always be exercised with care 
to avoid injury. Anxiety to arrive at a correct diagnosis may lead to 
rupture of a tubal collection or an ectopic gestation sac and necessitate 
prompt operation to save life. I have seen two patients and have been 
told of others in whom examination was followed by rupture of ectopic 
gestation sacs with death from internal hemorrhage. 

DIAGNOSIS : INSTRUMENTAL EXAMINATION. 

52. Instrumental Examination. In office practice the physician 
should have in a tray the following sterilized instruments: a large and 
small bivalve speculum, a Sims' speculum, a rectal speculum, long uterine 




Fig. 58. — Rectovesical Palpation. Sound in Bladder. 



dressing forceps, single and double tenacula, probes and applicators, 
sharp and dull curettes and scissors, angular and curved on the flat. 
The order recommended for instrumental examination formerly was, 
first, the use of the sound and then of the speculum. The difficulty. 



86 



GYNECOLOGY, 



however, in rendering the vagina sterile has led justly to the reverse 
procedure. The sound is a long, flexible instrument, 25 cm. in length, 
2 or 3 mm. in diameter, terminating in a bulbous end. It generally has a 
slight elevation about 6 cm. from its end, which indicates the normal 
length of the uterine cavity. For convenience in measurement its pos- 




FiG. 59. — ^Simpson's Sound. 

terior surface is marked by a scale in inches or centimeters. The instru- 
ment should be perfectly smooth, having no notches or indentations 
which may serve to retain infection. It is made of silver, or copper 
which has been silver or nickel plated, and should be sufliciently flexible 




A-l 



3 



Fig. 60. — Sims' Probe. 



to admit of its being readily bent. The handle should be roughened 
upon one side so that the concavity of the instrument can always be 
determined. Such an instrument is known as Simpson's sound. Sims 
advocated the use of a finer and more flexible instrument, known as 
the probe. 



Fig. 61. — Whalebone Probe. 



53. Probes are made of metal, hard rubber, and whalebone. The 
metal probe may be made of twisted steel and covered with a rubber 
sheath, rendering it more flexible. (Fig. 62.) The uses of the sound or 
probe are to ascertain the patency of the cervical canal, the depth of the 




Fig. 62.— Spring Probe Covered with Rubber. 

uterus, its width or capacity, the thickness of its walls, the presence 
of intra-uterine tumors, the condition of the mucous membrane, the 
direction of the uterine canal, and the mobility of the uterus. In treat- 
ment it has been used to replace the displaced uterus. The experienced 
physician will be able to obtain much of this knowledge fully as effectually 



DIAGNOSIS. 



87 



by the bimanual examination, and in the majority of cases the disadvan- 
tages of the instrument greatly outweigh the value of the information 
obtained by its use. It affords knowledge as to the patency of the canal 
which can not otherwise be determined; in all other instances the omis- 
sion of its use is preferable to its employment. It is true it is capable of 
affording information as to the direction of the uterus when the situation 
of that organ is rendered doubtful by the presence of inflammatory exudate, 
but in such cases its use is contraindicated. Our inability to secure an 
aseptic vagina should lead to the introduction of the instrument through 




Fig. 6^. — Introduction of the Sound. 



the speculum, and then only after the vault of the vagina has been care- 
fully mopped with absorbent cotton wet with a 2 per cent, solution of 
formalin. It is almost impossible to introduce the instrumicnt without 
injuring the mucous membrane of the uterine cavity, an injury which 
will afford a favorable culture field for the development of germs which 
are found in the vagina, or, exceptionally, even in the cervical canal. 
Such injuries explain the inflammatory irritation following the use of 
the sound and still further demonstrate the wisdom of discontinuing its 
employment for replacement of the uterus. When it seems desirable 
to use the sound without the speculum, the vagina should be scrubbed 
previously and two fingers introduced to the cer^^ix, by which the sound 
is guided into the os. (Fig. 6^.) No force should be employed and the 



ss 



GYNECOLOGY. 




Fig. 64. — Ferguson's Speculum. 



instrument should have such a curve as will permit it to pass readily in 
the direction which a bimanual examination has demonstrated to be that 
of the uterine cavity. The date of the last menstruation must be known, 
and the use of the instrument should be avoided when there is the slighest 
suspicion of pregnancy. It should not be employed in the presence of 
acute inflammation or when inflammatory exudate or old infiltrations can 
be determined. Its employment in a case of malignant disease may lead 
to dangerous hemorrhage. In the uterus softened and rendered friable 

by inflammation the sound may 
penetrate its wall and enter the 
abdominal cavity. This acci- 
dent produces no inconvenience 
unless the instrument carries in- 
fection. The sound may also 
pass into a Fallopian tube. 
This is more likely to occur in a 
bicornate uterus. The instru- 
ment should be scrupulously clean, indeed, should be sterilized by 
boiling, or when this is inconvenient be removed from a 5 per cent, 
solution of carbolic acid prior to its use. After its use the instrument 
should be sterilized by heat. 

54. Specula. A patient placed in the dorsal position, with the 
limbs separated, reveals the mons veneris, with the larger labia. The 
latter are separated by a cleft or slit— the rima pudendum. Frequently 
the labia minora are elongated, and they, with the clitoris, are prominent. 
The posterior commissure may 
have been injured, and, instead 
of a slit, we will have a triangular 
opening, through the posterior 
part of which projects the vaginal 
wall. In lacerations of the pel- 
vic floor its posterior segment 
may be drawn back, permitting 
one or two inches of the vagina 
to be inspected. Frequently by 
hooking back the vagina with 
two fingers the cervix can be 
seen. The necessity for satisfac- 
tory inspection of the uterus led 
to the invention of a great variety 
of instruments for this purpose, 
but all may be classed in two divisions: the tubular and the valvular 
speculum. 

The tubular speculum known as the Ferguson speculum may be made of 
glass, wood, rubber, celluloid or metal. The instrument is cylindric, 
the external end with a flange, the internal end beveled. It has one 
long side. (Fig. 64.) Glass instruments may be made of milk glass as 
the German speculum, or covered with quicksilver under a coating of 




Fig. 65. — Milk-glass Specula. 



DIAGNOSIS. 



pitch or rubber. (Fig. 65.) Such specula can not be steriUzed by heat; 
glass is brittle, easily broken, and useless subsequently. They are very 
serviceable in making applications to the cervix, but only the wooden 
instruments are of value in use of the actual cautery. The application 
of medicaments to the uterine canal or the use of the sound through it 
are to be condemned. The tubular speculum is not self-retaining. Its 
range of application is so limited that it is seldom used now. To intro- 
duce this instrument the 
physician separates the 
labia with the left hand 
and holds the speculum 
with the right thumb and 
middle finger on either 
side and the index-finger 
on its upper surface. The 
longer side is placed 
against the posterior 
commissure of the vulva,, 
which is depressed, and 




Fig. 66. — Nott's Speculum. 



the speculum is pushed upward and backward, at the same time rotating 
the instrument so that its shorter side does not impinge against the tender 
anterior structures. The situation of the cervix has been previously 
located by the touch. If the cervix is not brought at once into the field 
of the speculum, it can be exposed usually by rotating the instrument 
When this procedure fails, it may be drawn into the field by a tenaculum. 




Fig. 67. — Higbee's Specula (three sizes). 



If the cervix is large, only a part of it can be exposed at one time, and 
consequently a distorted idea of the condition is frequently obtained. 
The valvular speculum may have one or more valves, and is called 
univalve, bivalve, tri valve, or quadri valve according to the number of its 
blades. These specula afford a much better exposure. Those with more 
than one blade are self-retaining, therefore they have largely supplanted 



90 



GYNECOLOGY. 




Fig. 68. — Talley's Speculum. 



■ the tubular intrument. The quadrivalve instrument is now rarely used, as 
it affords but slight additional advantage over the bivalve. Besides 
it is difficult to keep clean. The Nott (Fig. 66) and Nelson specula have 
three blades and afford an opportunity to inspect the anterior vaginal wall. 
The bivalve speculum is the most satisfactory for general use. Of the 
great variety of specula, Higbee's (three sizes) (Fig. 67), Talley's (Fig. 
68), and Goodell's (Fig. 69) are probably the most satisfactory. The 
blade should be from 7.5 to 11 cm. in length. When the vaginal 
portion of the cervix is short, the Higbee speculum, which has a long 
posterior blade, will not expose the os. In such cases the Goodell or Talley 

specula, with blades of equal 
length, are better. The specu- 
lum is introduced by separating 
the vulva with the fingers of the 
left hand, while the instrument, 
held in the right, is introduced 
with its transverse diameter par- 
allel to the long diameter of the 
vulva. As the widest diameter 
of the vagina is at right angles 
to that of the vulva, the instru- 
ment is rotated and carried up- 
ward, directing the blades behind the cervix, the position of which 
has been previously determined by a digital examination. As the 
blades are separated the cervix is generally exposed. In marked 
anteversion it may be necessary to use a tenaculum to bring the cervix 
into view. The speculum is a therapeutic instrument, although it con- 
firms the diagnosis which has been made by digital examination. 

The univalve or duck-hill speculum, introduced by Sims, is used 
with the patient in the semiprone position. (Fig. 70.) The instrument 
has two blades at either 
end of a handle, which are 
about 10 cm. long, the 
smaller blade being 1.5 
cm. and the large blade 4 
cm. in width. To intro- 
duce this instrument the 
physician raises the but- 
tock, passes the blade with 
its width parallel to the 
vulva, and after its entrance rotates it with the handle directed backward. 
The assistant then holds the other blade with the right hand, using the in- 
strument as a retractor. (Fig. 71.) His elbow is held against his hip, while 
the left arm rests upon the patient, the hand elevating the buttock. Care 
must be exercised to follow the curve of the sacrum or the instrument 
will slip out. As the perineum is drawn back the vagina is ballooned by 
the atmospheric pressure and the cervix and upper vagina are exposed. 
When the vagina is large, with relaxed walls, the cervix may be obscured 




Fig. 6). — Goodell's Speculum. 



DIAGNOSIS. 



91 



from view. The depressor (Fig. 72) to push back the anterior wall 
or a tenaculum (Fig. 73) hooked into the cervix will overcome the 
difficulty. The* univalve 
speculum affords a better 
exposure of the cervix and 
upper portion of the vagina 
than any other form of 
instrument. Its particular 
disadvantage is that it is 
not self-retaining, and in 
office practice requires the 
asistance of a nurse. 
Various devices (Fig. 74) 
have been instituted to ren- 
der it self-retaining, but 

they require considerable time for their use. In operating with the patient 
in the semiprone position, the irrigating fluid and blood run forward between 
the patient's limbs, and hence render it difficult to keep her person and cloth- 




FiG. 70. — Sims' Speculum. 




Fig. 71. — ^Proper Method of Holding Sims' Speculum. The cervix brought into view 

with the tenaculum. 



ing clean. The Sims speculum can be used with the patient in the lith- 
otomy position, but it is uncomfortable to hold. The Simon posterior 
and side retractors serve a similar purpose. (Fig. 75.) The perineal 



92 



GYNECOLOGY. 



retractor known as the Edebohls speculum (Fig. 76) is the most satis- 
factory. With the patient upon her back, and the limbs acutely flexed, 
the perineum is retracted and held back by a weight attached to the 
instrument. (Fig. 77.) The cervix and the upper and anterior vagina 
are thus exposed to manipulation. 

55. Uterine Fixation and Downward Traction. Reference has 




Fig. 72. — Sims' Depressor. 



Fig. 73. — Goodell's Tenaculum. 



already been made to the use of the tenaculum to bring the cervix into 
the field of the speculum. The same instruments, or, better, a double 
tenaculum known as bullet-forceps (Fig. 78), guided to the cervix by 
the finger, may be used to fix the organ, or in some cases to exert traction 
upon it during digital examination. (Fig. 79.) Such a procedure en- 
ables us to examine through the rectum the whole posterior surface of the 

uterus and even to pass the 
finger over its fundus. It is 
utilized in replacing the re- 
troverted and retroflexed organ 
and in differential diagnosis 
of abdominal and pelvic 
growths. 

56. Dilatation of the 
Uterus. It is frequently 
necessary to explore the cavity 
of the uterus, either to com- 
plete the diagnosis of a con- 
dition rendered probable by 
other procedures or as a pre- 
'liminary to an operation. 

The method of operation 
may be divided into two 
classes: the first is bloodless and includes the use of tents, divulsion, and 
gradual dilatation; the second, incision of the external os and bilateral inci- 
sion of the cervix. Before practising any of these procedures the presence 
of inflammation in the organ or vestiges of inflammatory exudate about it 
should be excluded. The existence of such conditions presents an ele- 
ment of serious danger. 

Dilatation hy Tents. Formerly the use of tents was a popular and 
general method of dilatation. The materials used for this purpose 




Fig. 74. — Self-retaining Sims' Speculum. 



DIAGNOSIS. 



93 



were sponge, laminaria, tupelo, slippery elm, decalcified ivory, and gen- 
tian root. The sponge has the greatest dilating power, but is the most 
difficult to render aseptic and to maintain in that condition. The fre- 




FiG. 75. — Simon's Retractors. 

quent unfortunate sequelae that followed their use have led largely to 
their discontinuance. The laminaria (Fig. 80) and tupelo tents are 




Fig. 76. — Edebohls' Speculum. 



Fig. 77. — Edebohls' Speculum in Position. 



the most used. The former may be introduced in nests. Their dilat- 
ing power is enhanced by having them hollow. A number of small ones 




Fig. 78. — Double Tenaculum Forceps. 

to fill up the canal is to be preferred to one large tent. They may be 
rendered aseptic by subjection to a dry heat of 250° F. The tent should 
be placed in an envelope before its introduction into the sterilizer, and 



94 



GYNECOLOGY. 



the envelope should be broken only when it is to be used. The tents 
may also be rendered safe by immersion prior to their use in a saturated 
solution of iodoform in ether. Pozzi advocates their immersion in equal 




Fig. 79. — Traction upon Uterus with Double Tenaculum during Digital Examination 

by the Rectum. 

parts of carbolic acid and alcohol. They may be placed in 95 per cent, 
carbolic acid for a few minutes and afterwards washed in alcohol before 
insertion. I prefer immersing the laminaria tent in tincture of iodin 
for a few minutes before it is employed. The vagina and cervix should 




Fig. 80.— -He 



Laminaria Tent. 



be cleansed carefully with an antiseptic solution; the cervix is seized through 
the speculum with bullet forceps, while the tents are held in dressing 
forceps, and introduced, one after another, until the canal is filled. 
(Fig. 81.) Care must be exercised to mold the tents to the curve of the 




Fig. 81. — Uterine Forceps — Dressing. 

canal, and no force should be employed in their introduction. The 
tents should project from the external os, and should be held in place 
by a tampon of iodoform gauze. They should be removed at the end 
of ten or twelve hours, although they may be permitted to remain twenty- 



DIAGNOSIS. 95 

four hours. They are removed by pulling upon a string fastened to 
the end of the tent. Removal is sometimes rendered difficult by irregu- 
lar dilatation; the internal os, being more resistant, causes an hour-glass- 
shaped distention. (Fig. 82.) The tent is removed by placing the 
finger against the cervix during traction. The irregular dilatation is 




Fig. 82. — Dilated Tent Showing Constriction from Internal Os. 

less likely to occur with a tupelo tent, though its dilating power is not so 
great. Pain during the dilatation can be relieved by the use of from 
2 to 5 grains of acetanilid or from 1/4 to 1/2 of a grain of codein. The 
removal of the tent should be followed by careful antiseptic irriga- 
tion, after which another tent or series of tents may be introduced. The 




Fig. 83. — Ellinger's Dilator. 

use of the tent affords an opportunity to make a digital exploration of 
the uterine cavity, and is of advantage in small submucous fibroids, in 
suspected epithelioma, and in retained products after abortion. 

Divulsion consists in the rapid dilatation of the uterine canal by the various 
dilating instruments. The preferable instruments are the parallel bar 



Fig. 84. — Goodell's Modification of Ellinger's Dilator. 

dilators, such as the Ellinger (Fig. d>^), with the Baer and Goodell modi- 
fications (Fig. 84); the latter, with its roughened blades, is a powerful 
instrument. The vagina and cervical canal are carefully cleansed, and 
through the speculum the cervix is seized with a double tenaculum and 
stretched with small dilators, and subsequently with the large instrument 
to the extent of 2 or 3 cm., if desired. The principal objection to the 



96 



GYNECOLOGY. 




procedure is that the pressure is confined to the lateral surfaces of the 
cervix and, therefore, may lead to laceration. 

Gradual dilatation is accomplished by the use of graduated bougies, 
made of steel or hard rubber. The former are preferable, as they can be 
sterilized by heat. The Pratt series of bougies, which have two bougies to 
each handle, making eighteen in the set, the maximum being No. 51, 
will be useful. (Fig. 85.) Each bougie is 2 mm. larger than the preced- 
ing. After thoroughly cleansing the vagina and cervix the Edebohls, 
speculum is introduced, the cervix is seized with vulsellum or, better, 
two double tenacula and the bougies are used one after another, up to 
the largest size. (Fig. 86.) Care should be exercised not to puncture 

the uterine wall. This 
accident is more likely to 
occur in acute flexions; or 
where the wall has been 
softened by acute inflam- 
mation or recent preg- 
nancy. The point of the 
instrument makes so much 
pressure upon the thin 
convex wall near the flex- 
that finally it rup- 



lon 

tures. Rupture or per- 
foration of the uterine wall 
is not of infrequent occur- 
rence, and when done by the bougie has little significance. The tear by 
the parallel bar dilators is more serious, as the wall of the uterus is torn 
as wide as the dilators have separated. Through such an opening, omen- 
tum or a knuckle of intestine may be drawn into the uterine cavity. It 
is sometimes advised to precede this method by the use of a tent, but 
this does not seem necessary. The dilatation can be accomplished by 
the bougies in shorter time than by divulsion. 

Dilatation by Gauze Packing. VuUiet has devised a procedure for 
prolonged dilatation, which he denominates a "method of dilatation by 
progressive plugging." It consists in repeated plugging of the cervical 
canal with medicated gauze. After the uterus has been carefully cleansed, 
strips of gauze are packed into the cervical canal until it is completely 
filled. These are permitted to remain for forty-eight hours, when they 
are removed. If the uterus is not then dilated sufficiently to admit the 
finger, the cavity is again cleansed and packed. Pieces of compressed 
sponge have been used for a similar purpose, and, from their increase 
in size under moisture, are probably more effective. The only source 
of anxiety is the uncertainty as to their being absolutely sterile. This 
plan of procedure may be carried over a series of days or weeks, without 
inflammatory reaction. It is, however, not effective in cases of rigid 
cervix, and the same purposes may be accomplished by a more rapid 
dilatation. 

Incision of the Cervix. The external os, when very rigid, or when the 



Fig. 85. — Pratt's Dilators. 



DIAGNOSIS. 



97 



cervical canal is partly dilated by an extruding fibroid, may be incised. 
This procedure may be resorted to for abortion in the absence of proper 
dilating instruments. An incision from i cm. to 1.5 cm. should be 
made with scissors upon either side. As the ordinary scissors slip off, 
the Kuchenmeister scissors (Fig. 8j) are more effective. The procedure 



■^^S,!. 



\ 




Fig. 86.— The Method of Dilatation with the Graduated Bougies. 

is most readily accomplished by grasping each lip with a double tenac- 
ulum and incising on either side with a knife. The operation completed, 
the incised cervix should be closed with sutures. 

Complete bilateral incision of the cervix is rarely indicated, as other 




Fig. 87. — Kuchenmeister's Scissors. 

measures are less severe. The operation may be supplemented, if 
necessary, by ligation of the uterine arteries. The vessels may be 
secured by drawing the cervix to one side and passing a ligature with a 
strongly curved needle. Care should be exercised to keep close to the 
uterus and not to carry the ligature forward of a line tangent to the 
7 



98 



GYNECOLOGY. 



anterior circumference of the cervix, in order to avoid ligation of the ureter. 
A second ligature is passed upon the opposite side, when the cervix can 
be. incised with a knife to the vaginal fornix on either side without danger 
of hemorrhage. Although generally advised that ligation should precede 
incision, it is not necessary. Hemorrhage does not always occur. When 
it does, the bleeding vessels can be seized with forceps and then ligated. 
If the finger cannot be passed through the internal os, the canal can be 
still enlarged further with a probe-pointed bistoury. After exploration 
or operative procedure the cervix should be sutured carefully. Lateral 
ligatures should be removed in two or three hours, or in a shorter time if 
there is any reason to fear that the ureter has been ligated. Prolonged 
retention of the ligatures would result in sloughing of the vagina. 

EXPLORATION OF THE URETHRA, BLADDER, AND 

URETERS. 



57. The bladder can be explored by the introduction of the finger 
through the urethra, but the dilatation required is so great that, notwith- 
standing every precaution which can be exercised, the procedure is 
often followed by loss of sphincter control. A careful urethral and 
vesical examination may be made desirable by frequent and painful 
micturition; by admixture with the urine of blood, pus, desquamated 
epithelium, fragments of tissue; and the presence of bacteria. Limita- 
tion of the inflammation to the urethra is indicated by a pain and burn- 
ing during the act of urination, followed by comparative comfort (unless 
complicated by cystitis) unaccompanied by frequency of micturition. 
Inspection will reveal the orifice of the inflamed urethra as red, pouting, 
and angry. Frequently by pressure along the course of the canal from 
above downward a drop or two of dirty or purulent fluid will be ex- 
pressed. When the inflammation involves the wall of the urethra, it can 

be distinguished readily as a distinct 
cord-like projection on 'palpation of 
the anterior vaginal wall. Skene's 
urethral endoscope is of value in deter- 
mining the condition of the urethral 
mucous membrane. (Fig. 88.) It 
discloses points of inflammatory red- 
ness, desquamated epithe lium, thick- 
ened membrane, and fissures of the 
internal urethral orifice. The instru- 
ment should not be unduly large, as the distention of the urethra 
obscures pathologic alterations. Irritation and inflammation of the 
bladder is indicated by frequent and painful micturition and vio- 
lent tenesmus unrelieved by urination. The attacks may recur and ap- 
pear to be induced by exposure to colds, as drafts, changes of temper- 
ature, dampness, indiscretions in diet and drinking, and by excessive 
venery. The discomfort may be more or less continuous. The distress- 
ing symptoms may have arisen from infection which has reached the 




Fig. 88. — Skene's Urethroscope. 



EXPLORATION OF THE URETHRA. 



99 



bladder from the urethra, or the kidney through the vesical walls; or 
from the presence of foreign bodies, as calculi, fragments of catheter, 
or extraneous bodies which have been inserted into the urethra in the 
process of onanism. The existence of the various neoplasms may be 
manifested by similar symptoms. Inflammation of one or both ureters is 
apt to be associated with pain, which may be referred to the bladder. In- 
continence of urine associated with a forcible dejection of the fluid in 
small quantities is especially characteristic of inflammation of the ureter. 
Examination of the urine is of particular value in the determination of 
the lesions of the various portions of the urinary tract. In urethritis 
and functional irritation of the blad- 
der, the urine will be clear and free 
from deposits. In cystitis, ureteritis, 
and pyelitis the urine may be loaded 
with sediment, which, under the mic- 
roscope, will be found to consist of 
blood and pus corpuscles, renal and 
vesical epithelium, portions of tissue, 
crystals of the various salts, and in 
some cases casts of the uriniferous 
tubules. The determination of the 
portion affected by the character of 
the desquamated epithelium is imprac- 
ticable. The examination of urine 
secured after careful irrigation of the 
bladder, or, better still, after the cathe- 
terization of the ureters, not only 
differentiates renal from vesical condi- 
tions, but affords information as to the 
state of the individual kidney. If 
after irrigation of the bladder the urine 
secured is clear and comparatively 
free from sediment, it is a fair infer- 
ence that the disorder is confined to 
the bladder; and, on the contrary, the 
continuation of pus blood, and des- 
quamated epithelium in the urine is 
an intimation that the upper urinary 
structures are the seat of disease or 
are actively involved by it. Inflam- 
mation of the bladder causes the secre- 
tion of a large quantity of mucus, and the urine contains but little albu- 
min, while in inflammation of the pelvis of the kidney the proportion of 
albumin is comparatively large. Pyelitis is distinguished from nephritis 
by the absence of tubular casts. Bloody or highly colored urine is not 
uncommon in acute inflammation of the kidney or bladder. Hemor- 
rhage from the urinary tract may occur from a variety of causes and from 
any portion of the tract. From the urethra it may occur independently 




Fig. 89. — Cystoscopes. 



lOO GYNECOLOGY. 

of urination as a few drops or clots in the first discharge of urine, or after 
the completion of micturition. Vesical hemorrhage may cause the urine 
to be bright red or appear as almost pure blood, according to the severity 
of the hemorrhage. When very profuse, the bladder may become filled 
with clot, so that the patient is unable to void urine, and the presence of 
the clot interferes with catheterization. Free bleeding from the kidney 
may be seen with the cystoscope (see Fig. 89) , and makes its exit from 
one of the ureters as pure blood. Distinct casts of the ureter may be 
found in the urine, when the patient gives a history of severe pain over 
the kidney and along the ureter corresponding to the side from which 
the hemorrhage has occurred. Pain is a characteristic symptom. It 
is felt above the symphysis in cystitis, along the affected ureter in ureteritis, 
or over the affected kidney in pyelitis, or where the kidney contains a 
calculus. The hypogastric region is tender to pressure in cystitis. The 
tenderness is more noticeable upon sudden withdrawal of the hand after 
deep pressure when tubercular cystitis exists. The bladder may be 
palpated by one or two fingers in the vagina and the hand over the abdo- 
men. An inflamed bladder will be thickened, contracted, and very 
tender. Calculi and neoplasms may thus be recognized. The inflamed 
and thickened ureter is easily recognized upon one side or upon both 
sides when bilateral. The shortened ureters stand out as firm, dense 
cords. Not infrequently in such cases the pressure along the ureter may 
cause a sudden discharge of urine, which may be projected against the 
person of the investigator. 

An inflamed kidney is readily palpated when the patient assumes 
the dorsal position with the limbs flexed. The physician stands upon the 
affected side, places one hand upon the back beneath the ribs, and pushes 
gently forward, while at the same time the patient is asked to take a long 
breath and allow it to be expelled quickly. Pressing the thumb of the 
hand beneath the ribs in front during expiration the enlarged kidney 
may be felt to have slipped upward, or, where it is quite movable, may 
be held below the fingers. In thin patients the kidney thus may be 
distinguished easily. Care must be exercised, however, that a prolapsed 
or malformed liver is not mistaken for the kidney. In July, 1906, I saw 
a woman who, I was convinced after an examination under an anesthetic, 
had a very movable kidney. Examination through an abdominal 
incision, which was made for shortening the round ligaments, revealed 
the fact that the supposed movable kidney was a tongue-like projection 
from the anterior margin of the liver which, through the abdominal wall, 
greatly resembled the kidney in size and shape. 

Pawlik and Kelly devised specula through which the bladder may 
be inspected and medications applied to the most affected portion. 
The orifices of the ureters may be inspected and the ureteral catheter 
employed. These specula require the urethra to be dflated, sometimes 
close to or beyond the limit of safety, in order to afford opportunity to 
inspect and treat the affected structures properly. Of late years the 
procedure of Nitze renders the investigation more satisfactory. By 
this, the illuminating lamp is introduced within the bladder and its effect- 



EXPLORATION OF THE URETHRA. 



lOl 



iveness is increased by magnifying the image. The bladder is distended 
with water or air, preferably the former, when the entire cavity may be 
carefully inspected. The electric illumination can be obtained through a 
transmitter from the street current or the dry cell battery maybe employed. 




Fig. go. — Cystoscopic Investigation of the Bladder. 

An instrument not larger than a No. 30 bougie, French scale, is sufficient 
for every purpose in the inspection of the bladder and catheterization 
of the ureter. Such an instrument may be employed without an anes- 



^l||UMm||ui[ Q 




Fig. 91. — Kelly's Specula (Urethra). 





Fig. 92. — Mouse-tooth Forceps for Cotton Pleegets. 

thetic; the bladder may be irrigated and filled through the tube, after 
which its escape is perfected by the introduction of a magnifying lens. 
The cystoscopic inspection is of value, as it discloses the condition of the 
vesical mucous membrane, permits the differentiation of desquamation and 



I02 



GYNECOLOGY. 



catarrh from gonorrheal and tubercular cystitis, and has demonstrated the 
dependence of obstinate cystitis upon torpid ulceration of the vesical 
mucous membrane. It permits the inspection of the inflamed, pouting 
orifices of the ureters and allows the determination of the affected kidney 




Fig. 93. — Kelly's Evacuator. 



V 



Figs. 94 and 95. — Ureteral Catheters, Metal and Soft. 

by the observation of blood or pus coming from the orifices of the cor- 
responding ureter. It has permitted the recognition and dislodgment of 
calculi situated in the lower end of the ureter. The condition of the 




Fig. 96. — Harris' Double Catheter for Obtaining Urine from Kidneys Separately. 

ureter and kidney is also determined by passing through the posterior 
slit of the cystoscope a long, soft, ureteral catheter. This procedure 
permits the exploration of the ureter and the accumulation of the urine 
for examination, affording an opportunity to determine whether one or 



EXPLORATORY OPERATIONS. IO3 

both kidneys are involved. By a wax-tipped bougie, as suggested by 
Kelly, the presence of a calculus can be recognized in the ureter or in the 
pelvis of the kidney. 

The urine should be drawn and examined carefully before the cysto- 
scopic investigation is made. The segregator, as devised by Harris, of 
Chicago, will permit the accumulation of the urine from the kidneys in 
separate receptacles, but it is inferior to the use of the urethral catheter, 
through the cystoscopy 

DIAGNOSIS: EXPLORATORY OPERATIONS. 

58. Exploratory operations for the purpose of diagnosis may be one 
of the two classes: puncture and incision. Puncture is divided into two 
procedures; tapping and aspiration. The former is applicable to the 
diagnosis and treatment of ascites; the latter, where it is desirable to 
lessen the size or to determine the contents of a cyst. 

Tapping, or paracentesis abdominis, was at one time the only method 
of treating abdominal collections of fluid, whether free or confined within 
a cyst. The instruments used should consist of a trocar and cannula, 
about 1/8 of an inch in diameter, to which a rubber tube may be attached. 
If Wells' blunt cannula is used, a bistoury must be employed to make the 
incision. The patient is placed upon her side near the edge of the bed; 
a point is selected in the median line, about midway between umbilicus 
and symphysis, which percussion has demonstrated to be free from in- 



^Kl^S 



Fig. 97. — Nest of Trocars. 

testine. The surface is frozen by the application of ice and salt, or a 
spray of ethyl chlorid. The procedure can be rendered painless far more 
effectually by infiltrating the skin with Schleich's fluid introduced by a 
hypodermic syringe. An incision is made through the skin, and the 
trocar is plunged, by a quick, rotating thurst, into the peritoneal cavity. 
The finger is held upon the instrument to govern the distance it is to be 
introduced. The trocar is withdrawn and a rubber tube is applied to the 
cannula to convey the fluid into a receptacle. The complete evacuation 
of the fluid is secured by pressing upon the abdomen toward the cannula. 
Arrest of the flow by the intestines floating against the end of the cannula 
can be obviated by changing its position. As the contents are evacuated 
the entrance of air into the abdomen may be prevented by keeping the 
end of the rubber tube submerged. The cannula is withdrawn and a 
piece of aseptic gauze is placed over the opening and held by a small 
strip of plaster. The withdrawal of a large quantity of liquid is frequently 
followed by symptoms of syncope. The patient should be kept in the 
horizontal position and, if necessary, given per oram well diluted 
whisky or brandy (f5j), spt. ammon. aromat, f3j, strychnin sulphate 



I04 



GYNECOLOGY. 



(gr. 1/60 to 1/30), atropin sulphate (gr. i/ioo), hypodermically, hypo- 
dermic injections of an aseptic ergot, or inhalations of a few drops of 
amyl nitrite. 

Aspiration should be the procedure chosen when it is desired to evacu- 
ate the contents of a cyst. The use of the trocar favors the entrance of 
air and pathogenic germs. Its opening permits the escape of the cyst- 
contents into the peritoneal cavity, which not infrequently promotes 
the development of peritonitis. Consequently the contents of a cyst 
should be removed entirely if the wall has been perforated. The use of 
the hypodermic syringe for the withdrawal of a small quantity of fluid 
for examination is reprehensible. The patient encounters a greater risk 

from the escape of a portion of the con- 
tents of a tense cyst through even a small 
opening than can be compensated by any 
advantage derived from an examination of 
the fluid. For aspiration two instruments 
may be used. One in which the needle is 
connected with the reservoir will hold a few 
ounces, the other, used in large accumula- 
tions, consists of a large air-pump connec- 
ted by tubing with a needle, a quart bottle 
intervening. (Fig. 98.) Rapid suction ex- 
hausts the air in the bottle and causes the 
fluid to run until the cyst is emptied or the 
bottle filled. Strong suction, when the cyst 
is nearly empty, draws its sides into the 
Withdrawal of the contents of the cyst is an ad- 
visable procedure when the pressure of the tumor is so great as to obstruct 
circulation and lead to dyspnea, decreased renal secretion, and more or less 
anasarca. Operation in such cases, by facilitating the restoration of 
secretion, promotes a favorable result in subsequent removal of the 
cyst. The procedure may be necessary, also, to prolong the life of the 
patient until a skilled operator can be secured. Broad-ligament cysts 
are occasionally cured by aspiration. This affords an opportunity to 
clear up the diagnosis in otherwise obscure cases. Two conditions 
particularly can be determined by microscopic examination of the fluids. 
Hydatid disease is recognized by finding even a single booklet. Malig- 
nant disease is determined by the presence of blood-corpuscles or particles 
of malignant tissue. Blood is mixed with the fluid. To examine the fluid 
it should be drawn into a clean vessel, covered, and permitted to stand 
for twelve hours, when blood-corpuscles will be found at the bottom or 
adherent to the sides of the vessel. Tapping and aspiration should 
always be done through the abdominal walls, never through the vagina 
or rectum, on account of the difficult antisepsis and consequent danger 
of infection. 

Exploratory incision in cases of difficult or doubtful diagnosis is a 
most effective method for making known the condition, but should be 
infrequently practised. The more carefully the sense of touch is culti- 




FiG. 98. — Aspirator. 

needle and stops the flow. 



MICROSCOPIC EXAMINATION. 105 

vated, the less frequently will an incision be required. The position of 
a patient who has nerved herself to undergo an abdominal operation, 
only to ascertain that her trial and suffering have been without avail, 
is most distressing. It is not calculated to lead the surgeon to repeat 
it frequently in cases of extremely doubtful character. 

DIAGNOSIS: MICROSCOPIC EXAMINATION. 

59. Microscopic Examination. It is evident from the preceding 
that careful investigation of tissue changes is often necessary to confirm 
and add to the data secured by inspection and touch. The microscope 
here proves an important aid to diagnosis. It throws light upon obscure 
conditions, and affords opportunity for recognition of the incipient 
stages of lesions so insidious and grave that, were the investigator de- 
prived of the information it affords, an accurate diagnosis would frequently 
come too late for radical treatment. By means of the microscope knowl- 
edge of the histologic structure of the genital organs has been secured. 
It is apparent that it would prove equally valuable in betraying patho- 
logic alterations in the course and progress of disease. Consequently, 
it proves a valuable aid in diagnosis, forming by its findings definite 
ideas concerning prognosis and demonstrating suitable methods of 
treatment. 

60. Collection of Tissue. Tissue collected for microscopic ex- 
amination is procured by test curetment and test excision. Occasionally, 
sufficient tissue can be expressed from the genital tract or escape in dis- 
charges, from which reasonably satisfactory microscopical examinations 
can be made. Generally, however, only small particles of tissue escape. 
These usually indicate the existence of marked degenerative changes; 
therefore the tissue must necessarily be so altered by necrobiotic pro- 
cesses as to render positive microscopic diagnoses uncertain and difficult. 
Test excision is employed in cases of suspected disease in the lower 
part of the genital tract and cervix. Test curetment is performed in 
cases of suspected disease in the interior of the corpus uteri. In certain 
conditions these two methods of collecting tissue may be combined with 
distinct advantage. 

Test Excision. The method of collecting tissue from either the vagina 
or the cervix by test excision must be regarded as a surgical operation. 
Therefore the patient should be as carefully prepared as for a plastic 
operation. The bowel and bladder empty, the patient is placed in the 
dorsal position upon the table, the parts thoroughly cleansed, and the 
cervix exposed by introducing Edebohls' speculum or suitable retractors 
into the vagina; the cervix is then grasped with double tenacula, one upon 
each side or upon the anterior and posterior lip; and gentle traction is made 
to fix the organ nearer the vaginal orifice. With sharp scissors or scalpel 
a triangular or V-shaped piece of the cervix is so excised as to secure 
both healthy and diseased structure including a portion of the mucous 
membrane lining the cervical canal. The wound left from the excision 
should be closed with one or two sutures Df catgut. Closure of the wound 



Io6 GYNECOLOGY. 

is followed by irrigation of the parts with warm sterile salt solution; the 
vaginal canal is lighty packed with iodoform gauze and a sterile peri- 
neal occlusion dressing applied. It is better, in the majority of cases, 
to employ general anesthesia for test excision, although it can be done by 
anesthetizing the surface with a 2 per cent, solution of cocain applied on 
a cotton tampon. Infiltration anesthesia would permit of painless exci- 
sion, but it destroys the cell structure and would, consequently, be mis- 
leading. Each step of the procedure for test excision should be exe- 
cuted with the utmost delicacy in order to avoid disturbing the architect- 
ural construction of the tissue, and, therefore, alterations in the living 
histological cell picture. This cannot be emphasized too strongly. Un- 
fortunately, many surgeons collect tissue for investigation by the micro- 
scopist in so careless a manner that by the time the tissue reaches the 
pathologist's hands its structure is so changed as to render intelligent 
study almost impossible. 

The excised tissue should be washed in running water and carefully 
inspected with the naked eye then with a magnifying glass, by which its 
color, consistence, and general structure can be recognized and noted. 
During this inspection the question can be determined as to what course 
shall be pursued in fixing and preparing it for a more complete examina- 




FiG. 99. — Douche Curet. 

tion. As the tissue will undergo marked change in this process of fixing, 
it is wise that a drawing should be made and the direction determined in 
which the future sections are to be cut. Abel advises that excised por- 
tions be so divided that one part can be examined while fresh, and the 
other prepared for finer sections. 

Test Curetment. In employing the curet to secure material for examina- 
tion the same precautions concerning antisepsis and thorough preparation 
must be observed as in test excision. The operation is performed as 
follows : the patient is put under general anesthesia, in the dorsal position. 
The vulva and vaginal canal are thoroughly sterilized. The cervix is 
exposed by an Edebohls' speculum or suitable retractors, the anterior 
cervical lip fixed with double tenacula, the cervical and uterine canals 
delicately and carefully dilated. The utmost caution should be practised 
in every step of the procedure. Undue force must positively be avoided 
in order to prevent injury of the tissue cells and distortion of the his- 
tology of the collected tissue, which would render microscopic examination 
unsatisfactory. Dilatation is best accomplished by Pratt's graduated 
dilators. By their use rapid and uniform dilatation is secured, with but 
little congestion or traumatism to the endometrium. Uterine dilatation 
may also be secured by the use of laminaria tents. One or two are intro- 



MICROSCOPIC EXL^MINATION. 



lO' 



duced and allowed to remain for a period of twelve hours; when, if sufficient 
dilatation is not secured, a nest, comprising three or four tents, is intro- 
duced and allowed to remain twelve hours more. Dilatation by tents has 
the great advantage that it permits digital exploration of the uterine cavity. 
(See Dilatation.) This exploration, however, should follow the curet- 
ment, for the previous introduction of the finger would, to a certain degree, 
disarrange and render unsatisfactory the endometrium for microscopical 
examination. Tent dilatation has the disadvantage of requiring twelve 
to twenty-four hours, but this additional time is often compensated by 
the information afforded the exploring finger, because digital examina 




:%> 



1^ 




Fig. ioo. — Tissue Removed by Test Curetment. 

tion of the uterine interior may disclose lesions which the curet has 
failed to reveal. In the employment of either method described a 
high degree of dilatation should be secured. The uterus is cureted with 
a long, sharp douche curet having an acute angle. It is well to start the 
curetment at a fixed point, either the posterior or lateral wall, and with 
long successive sweeps, proceed from the fundus to the cervical opening, 
removing the membrane to the muscle structure. As the tissue escapes 
from the uterus it should be collected by an assistant in a sieve made 
of paraffin paper. (Fig. loo.) 

The collection of cureted tissue on sterile gauze is to be condemned. 
The tissue adheres to this material, and in its removal the individual 
elements are torn and distorted. Tissue thus collected is first examined 



Io8 GYNECOLOGY. 

microscopically and any peculiarities recorded, after which it should be 
immediately transferred to a fixing solution unless frozen sections are 
preferred. 

6i. Disposition of Tissue. That injuries result from undue and 
careless handling of tissue after test excision or curetment cannot be too 
strongly emphasized. Surgeons often fail to realize the value of avoiding 
careless manipulation of specimens and frequently destroy unwittingly the 
living cell construction by prolonged exposure of the specimen to the air 
and injudicious handling. The advantages of fixing the tissue immediately 
after removal are many. The wrapping of any specimen in gauze, as 
already mentioned, is to be positively condemned. Tissue so treated 
soon dries, the gauze becomes firmly adherent to it, and in its removal 
tears and disarranges the surface cells. In case the fixative agent is not 
at hand, cureted or excised tissue can, without harm or injury, be tempo- 
rarily placed in paraffin paper, although it is decidedly advantageous to 
have fixative agents prepared and ready for the reception of the material 
prior to its removal. By such means the individual cell elements are per- 
manently fixed as they occur in life, and the microscopist is thus enabled 
to study satisfactorily the cell chemistry and general cell construction 
of the specimens. When these are placed in fixative agents the vehicle 
containing them should be numbered and properly labeled. The label 
should contain the name of the patient, her age, the date of operation, the 
character of the operation, the part from which the tissue is obtained, 
together with a brief history. 

62. Examination. The specimens may be examined as teased 
specimens, or be cut with the freezing microtome. The latter course is 
preferable, as it interferes less with the relations of the structures, and 
consequently permits a more correct judgment as to the condition. 

By teasing, the elements are separated from each other when it is 
impossible to decide whether the surface epithelium sends processes into 
the tissues or whether a simple hyperplastic or destructive process exists — 
points of the greatest importance in arriving at a correct diagnosis. 

The fresh specimen should be cut with the freezing microtome, but 
the sections should not be too thin, as they are likely to tear in subse- 
quent manipulation. 

Each section is removed from the knife with a camel's-hair brush 
and placed in distilled water. To prevent the section from being torn 
in transmission to the slide, it is better to push the latter under the sec- 
tion as it swims in the fluid and hold it gently with a glass rod. 

The section, having been spread carefully upon the slide, is then covered 
with a fine cover-glass. The latter is grasped at one edge with forceps, 
the opposite side brought at an acute angle upon the fluid covering the 
surface of the slide and gently released, removing the superfluous fluid 
with blotting-paper. The section can now be studied with high or low 
power, but when unstained is best placed upon a dark under-layer. 

Specimens so studied show the cells as they were during life, and the 
character of the normal tissue or any degenerative process can thus be 
recognized. 



MICROSCOPIC EXAMINATION. IO9 

The specimen may be subjected to various microchemical reactions 
which will afford valuable information. The section may be rendered 
more transparent by a drop of a 2 or 3 per cent, solution of acetic acid 
placed under the edge of the cover-glass. A piece of blotting-paper 
held at the other side causes it to penetrate the section quickly. Fatty 
tissues may be removed by the similar use of alcohol, chloroform, or 
ether. 

Elastic fibers are rendered prominent by caustic soda in a i to 3 per 
cent, solution. Marked swelling of the contractile elements of smooth 
and striated muscles and of the nuclei occurs, and the horny substance 
becomes transparent. A ^;^ per cent, solution of caustic potash is es- 
pecially valuable as a preservative. Red blood-cells preserve their 
form well in such a solution. 

Infarcts are in no way so well observed as in fresh specimens. They 
may be permanently preserved by replacing the salt solution with gly- 
cerin, or preferably with a 55 per cent, solution of potassium acetate. 
Pick's method presents the best procedure for preserving frozen speci- 
mens, and consists in the use of alum-carmin combined with formalin. 

The alum-carmin of Grenach (4 to 5 per cent, of carmin) is added to 
Schering's formalin 10 to 100, which should be kept in a dark-colored 
bottle. 

Pick's process is as follows: 

1. Preparation of the frozen section with Jung's microtome. 

2. Transference of the section into a 4 per cent, formalin solution 
for fifteen seconds. 

3. Formalin-alum-carmin, two to three minutes. 

4. Washing in water, one-half minute. 

5. Eighty per cent, alcohol, one-half minute. 

6. Absolute alcohol, ten seconds. 

7. Carbol-xylol, one-half minute. 

8. Canada balsam. 

Coplin says that his experience convinces him of the necessity for 
fixing all tissues thoroughly before attempting to section them, other- 
wise the results are always open to criticism, because the distortion in- 
cident to congelation masses, maceration, and the difficulty of removing 
the infiltrates produce conditions which would mislead the most ex- 
perienced observer. He advises the following fluids : 

1. Flemming^s solution, which consists of: i per cent, aqueous solu- 
tion of chromic acid, 25 volumes; i per cent, aqueous solution of osmic 
acid, 10 volumes; i per cent, aqueous solution of acetic acid, 10 volumes; 
wa.ter, 55 volumes. 

All water in stock solutions and final mixtures must be distilled. 
Small pieces (5/10 to i c.cm.) will undergo sufficient fixation in one- 
half to two hours. After this process is complete they should be washed 
in running water for six hours. 

2. Hermann's solution: i per cent, aqueous solution of platinic 
chlorid, 15 volumes; 2 per cent, aqueous solution of osmic acid, 2 vol- 
umes; glacial acetic acid, i volume. 



no GYNECOLOGY. "^ 

3. Coplin regards corrosive sublimate solution as the most useful 
fixing agent for general use, although for pure cell study the first two 
solutions are probably better. It consists of 125 gm. of corrosive subli- 
mate dissolved in a liter of 0.5 per cent, solution of sodium chlorid in 
water. Small pieces fix in this solution in one-half to two hours. The 
used solution is filtered back into the stock solution, while the hardened 
tissue is washed in water, or preferably in 70 per cent, alcohol. This 
solution has the advantage of cheapness, keeping qualities, and simplicity. 

With any of these, the quantity of fluid should exceed several times 
the volume of tissue to be fixed. 

It is important for purposes of diagnosis that the tissues not only 
should be fixed properly, but that sections should be made with as little 
disturbance of cell relation as possible. Attention also must be given 
to the direction in which sections shall be made through the tissues. 
Sections parallel with the surface of a mucous membrane are of little 
value, as they cut across glands and afford no indication of the true 
character of epithelium. The most serviceable are the vertical or 
slightly oblique. 

Embedding. A small piece of tissue may be prepared for section- 
cutting by being embedded in either gelatin, celloidin, or paraffin. 

Glycerin- gelatin. Ten grams of the finest gelatin are placed in a 
clean vessel and covered with water. After four to six hours the water 
is poured off, and the mass liquefied by moderate heat. While stirring 
with a glass rod, 10 grams of glycerin and 5 drops of carbolic acid 
are added, and the mixture left in a wide-mouthed bottle. To embed 
a specimen, a piece of this mass is taken and liquefied by heat. A thin 
layer is poured upon a cork surface, the specimen placed upon it and 
covered with a mantle of gelatin which soon becomes hard. 

After being immersed in absolute alcohol for twenty-four hours 
good sections can be made. 

Celloidin. The specimen is placed for twenty-four hours in absolute 
alcohol, and the same length of time in sulphuric ether. It then remains 
twenty-four hours in a tight bottle containing thin celloidin. At the 
end of this period it is placed in a thick solution, a small opening being 
left so that the alcohol and ether evaporate very slowly. In a few hours 
a semi-solid mass has formed, a block of which containing the speci- 
men IS cut out, fastened with thick celloidin upon cork or wood, after 
which it remains for twelve hours in a 70 to 80 per cent, solution of 
alcohol, when it has the proper consistence for section-cutting. 

Paraffin. Abel prefers to stain the specimen preparatory to embed- 
ding in paraffin. The specimen, hardened in alcohol, is placed in the 
staining solution. This may be Bohmer's hematoxylin, eosin, or saf- 
ranin. It should remain in . a well-filtered solution two to eight days, 
according to its thickness. It is removed from the staining solution to 
70 per cent, alcohol for twenty-four hours, then is dehydrated in absolute 
alcohol. It is placed in xylol for twelve hours to prepare it for satura- 
tion with paraffin. The specimen is placed in a mixture of equal parts 
of xylol and paraffin, in which it remains for twenty-four hours, subjected 



MICROSCOPIC EXAMINATION. Ill 

to a continuous temperature of 37° C. in a paraffin oven, after which it 
is kept in paraffin at a temperature of 48° to 50° C. The latter is then 
permitted to solidify at the room temperature, when a paraffin block of 
suitable size containing the specimen is cut out and fastened to a cork or 
piece of wood with paraffin, after which it is ready for cutting. 

The sections thus secured are thinner than those secured by any other 
method. 

Section-cutting. Sections are preferably cut with a microtome and 
should be of equal thickness. A thickness of 3 to 5 microns will be satis- 
factory. 

The sections are conveyed with a camel's-hair brush to a basin con- 
taining dilute or absolute alcohol; the celloidin sections to a 70 per cent, 
solution of alcohol, the gelatin sections to absolute alcohol. The sections 
are very much shriveled by the alcohol and should be placed in water for 
several minutes before being transferred to the staining fluid. 

The paraffin sections cannot be transferred from one vessel to another; 
it is better to treat them on the slide. Abel applies i drop of a solution 
of collodion in alcohol upon a slide, and upon this the section, pressing it 
down with filter-paper. The paraffin is dissolved out with xylol, and 
covered with equal parts of xylol and Canada balsam, and over this the 
cover-glass is placed carefully. 

Staining. We will consider only those methods which are most- 
effective in rendering prominent the histologic structures we are desirous 
of utilizing in the diagnosis. Picrolithiocarmin and hematoxylin are 
both very satisfactory. 

Picrolithiocarmin, introduced by Orth, is prepared by uniting one part 
of lithiocarmin (a cold saturated solution of lithium carbonate in which 
carmin powder has been dissolved in the proportion of 2.5 grams of the 
latter to 100 grams of the former solution) with two parts of a saturated 
solution of picric acid. This stain is most suitable for specimens which 
have been hardened with alcohol. The section is placed in the staining 
solution by a spatula and remains five to ten minutes, from which it is con- 
veyed for one to two minutes to a solution of alcohol (70 per cent.) one 
hundred parts, hydrochloric acid one part, then washed in dilute alcohol 
and dehydrated in absolute alcohol. The specimen is made clearer by 
oil of cloves, oil bergamot, or xylol. It is conveyed to the slide and spread 
out free of folds. It is then mounted in Canada balsam. Horny cells, 
fibrin, hyaline substances, and red blood-corpuscles take on a yellow color. 
The nuclei of the epithelium become a pale pink, and the fibrillar tissue 
remains undyed, affording a clear picture of the specimen stained. Hem- 
atoxylin stain is prepared by Coplin after Delafield as follows: Dissolve 
4 gm. of hematoxylin crystals in 25 c.c. of strong alcohol; add this solu- 
tion to 400 c.c. of a cold, filtered, saturated aqueous solution of ammonia 
alum; expose to light and air for several days. Filter and add glycerin 
100 c.c. and methyl alcohol 100 c.c. This preparation is allowed to stand in 
light, with the bottle loosely corked; this mixture turns dark purple or 
almost black. After assuming this color it should be filtered and placed in 
tightly stoppered bottles. Before being used it should be largely diluted. 



112 GYNECOLOGY. 

If properly prepared this stain will last for years. The great objection 
to Delafield's mixture is that it requires time for ripening and therefore 
cannot be used immediately after being made. Harris has overcome 
this objection by preparing the mixture as follows: Dissolve i gm. 
of hematoxylin in lo c.c. of alcohol and add the resulting solution to 200 
c.c. of distilled water in which 20 gm. of ammonia or potassium alum 
have previously been dissolved. This fluid is heated in a flask to boil- 
ing, at which time i gm. of mercuric acid is added. The solution darkens 
(ripens) at once and is now ready for use, but should always be diluted. 
From this stock solution an acid hematoxylin may be prepared by adding 
4 c.c. of glacial acetic acid and 30 c.c. of glycerin to 70 c.c. to the primary 
solution. This acid preparation has the great advantage of rendering 
overstaining almost impossible. 

Hematoxylin Staining. To use the hematoxylin stain of Delafield 
or Harris the sections cemented to the slides are covered with the diluted 
stain from five to fifteen mintues. They are then washed in water, dehy- 
drated in alcohol, cleared with creasote, and mounted in Canada balsam. 
Coplin states that a better result is obtained by placing enough distilled 
water in a staining dish to immerse the slide on end. To this sufficient 
hematoxylin is added to tinge the water rather deeply. The sections 
adherent to the slides are permitted to remain in this solution twelve to 
twenty-four hours. They are then cleansed in water and treated as di- 
rected previously. Hematoxylin stains the nucleus purple and gives a 
faint tint to the protoplasm shapes. Definition of the protoplasm can be 
secured by following the hematoxylin staining if the slides and section are 
placed in an 0.5 alcoholic solution of eosin for one or two minutes. The 
excess of water is removed and section washed in alcohol, cleared in 
creasote, and mounted in balsam. This method stains the nuclei purple 
and the surrounding protoplasm pinkish. Moreover, the eosin stains the 
erythrocytes present. One of the very best contrast stains is that sug- 
gested by Van Geison, which is composed of the following: 

Acid fuchsin (i per cent, aqueous solution), 15 c.c. 

Picric acid (saturated solution), 50 c.c. 

Water, 50 c.c. 

In using this stain the sections are first stained with hematoxylin, 
washed in water, followed by applying the Van Geison* stain for four or 
five minutes, dehydrated in alcohol, cleared in xylol, and mounted in 
xylol balsam. By this method the connective tissue appears red or pink- 
ish-red, the cell protoplasm yellow, and the nuclei dark brownish or 
reddish-purple. 

Hematoxylin stain is prepared by dissolving i gram of hematoxylin 
in 30 grams of absolute alcohol. To a solution of powdered alum 
(0.5 to I gram in distilled water 30 cm.) the above preparation is added 
drop by drop and shaken until the fluid takes a deep violet color. 

Celloidin-embedded sections remain ten to twenty minutes longer, 
according to size and thickness, in the solution than sections prepared 
by other methods, and are placed in alcohol containing hydrochloric 



MICROSCOPIC EXAMINATION. II3 

acid until they begin to assume a red tint, from which they are removed 
to 70 per cent, alcohol. They are placed in absolute alcohol until the 
mantle of celloidin begins to curl. Care must be exercised that all the 
celloidin is not dissolved or the finer sections would fall to pieces. The 
section is made transparent in oil of bergamot or in xylol. Should the 
celloidin mantle at this stage become cloudy or milky, the section should be 
placed in absolute alcohol until it clears. The section is placed upon a 
slide with a spatula and mounted in xylol-Canada balsam after removing 
the oil with filter-paper. This method gives splendid staining of the 
nuclei, the protoplasm is slightly stained, the celloidin not at all. The 
diagnosis of malignant conditions is greatly enhanced by staining the 
elastic fibers. For this purpose Taenzer's orcein stain is employed. 
The sections are taken from water and kept in this solution from six to 
twelve hours or longer (Griibler's orcein 0.5, alcohol 40.0, aq. dest. 
20.0, hydrochloric acid gtt. xx), then placed for a few seconds in hydro- 
chloric acid alcohol (hydrochloric acid o.i, 95 per cent, alcohol 20.0, aq. 
dest. 5.0), where they become differentiated and are washed in water. 
After five to ten minutes' dehydration in absolute alcohol, they are cleared 
in oil and mounted in Canada balsam. 

The elastic fibers appear as an intense red upon a pale pink back- 
ground. 

Weigerfsfuchsin-resorcin stain is made by taking 200 c.c. of the fol- 
lowing mixture: Resorcin 2.0, fuchsin i.o, distilled water 100. o, and 
bringing it to a boil in a piocelain vessel, when 25 c.c. ferri liq. sesqui- 
chlor. (German Pharmacopeia) are added, the whole stirred while 
boiling for two to five minutes longer. The muddy mass thus formed 
is permitted to cool and is filtered. The portion which runs through the 
filter is thrown away, and the deposit left upon the filter until it ceases 
to drip. 

The filter with its contents is removed from the funnel, placed in a 
bowl, and boiled under constant stirring with 200 c.c. 94 per cent, 
alcohol. While boiling, the filter-paper is removed and the solution is 
permitted to cool, after which it is filtered and the filtrate brought to 
200 c.c. by the addition of alcohol. After adding 4 c.c. of hydrochloric 
acid the solution is ready for use. 

The sections are placed in this solution for twenty minutes to one 
hour, washed in alcohol, and cleared in xylol. 

The elastic fibers are stained dark blue, almost black, on a quite 
light background. The nuclei may be stained with a carmin preparation. 

63. Preservation of Gross Specimens and Slides. In order to 
keep a complete case record it should be the rule to preserve the gross 
specimens and slides containing sections therefrom. Many agents have 
been recommended for the preservation of gross specimens. Alcohol 
is perhaps the reagent most commonly employed, but by its use the density 
of the specimens is altered, the color entirely lost, and general outline 
indifferently retained. Formalin has recently gained considerable 
prominence as a valuable preservative. A 10 per cent, solution of the 
commercial preparation is usually employed. Specimens prepared by 

8 



114 



GYNECOLOGY. 



this method can be used with a higher degree of satisfaction for histo- 
logic study than those prepared with alcohol. Specimens when not too 
large can also be preserved in formalin vapor by placing them in an air-tight 
jar containing a bed of cotton which has been previously moistened with 
pure formalin. The specimen should be placed upon the cotton and 
covered with filter-paper moistened with the reagent. For the retention 
of the color of gross specimens no method possesses such advantages as 
those afforded by the use of Kaiserling's solution. Two solutions are 
necessary and are composed of the following. 

Solution A. 

Formalin, 250 c.c. 

Nitrate of potassium, 10 gm. 

Acetate of potassium, 30 gm. 

Water, i liter. 

Solution B. 

Acetate of potassium, 200 gm. 

Glycerin, 400 c.c. 

Water, 2000 c.c. 

Formalin, to point of saturation. 

The specimen prior to being placed in the preservative is lightly 
washed with running water to remove adhering blood and is then placed, 
according to size, from one to twenty-four hours in Solution A, at the end 
of which period it is changed to a fresh Solution A, in which it is allowed 
to remain from two to thirty-six hours. It is then washed in running 

water from fifteen minutes to one hour 
and placed in 80 per cent, alcohol in 
order to cause a reappearance of the 
color. Unless the color shows signs of 
returning the specimen in transferred 
to 95 per cent, alcohol, in which it is 
allowed to remain until the color is fully 
restored. After the color is thus re- 
stored the specimen is placed in Solution 
B and at the end of twenty-four to 
forty-eight hours it should be placed in 
a fresh portion of Solution B. 

To preserve slides the best results 
are obtained by using a card index sys- 
tem. Special histologic or slide cases are 
made containing trays for the slides and 
also a card index as shown in Fig. loi. 
By using this method the slide is labeled and numbered. A corres- 
ponding number is on the index card which contains the name of 
the patient, her age, date, occupation, name of organ from which 
tissue was removed, and pathologic diagnosis. An ingenious slide 
card index has been devised by Coplin. (Figs. 102 and 103.) The 




Fig. ioi. — Cabinet with Trays and Card 
Index for the Preservation of Slides. 



MICROSCOPIC EX.A.MIXATIOX. 



Ii: 





slides are properly labeled, numbered and then placed in the card 
and secured by sealing the free end of the card paper. The index 
card is marked as de- 
scribed above. The cards 
containing the slide are 
preserved in dust proof 
drawers. This method 
offers the advantage that 
the slide cannot be sepa- 
rated from the name of the 
patient, and from its inge- 
nious arrangement can be 
submitted to microscopic 
examination without remo- 
val from the card. 

64. Failure. Exami- 
nation may fail to reveal 
the true character or pres- 
ence of disease, because 
the section was made 
through the adjoining 
healthy tissue. The ex- 
amination may also prove 
unsatisfactory and worth- 
less as a result of mutilation 
and distortion of the speci- 
men incident to undue 
manipulation; carelessness 
in preparation for study. 

65. Bacteriology of the Genital Tract. The importance of care- 
ful bacteriologic examinations of the secretions of the genital tract cannot 

be overestimated. Care- 
ful bacteriologic analyses 
of the genital secretions 
not only increases the 
clinical interest of a case, 
or special cases, but stimu- 
lates scientific research, 
and, therefore, renders the 
case records complete and 
more worthy of preserva- 
tion. Furthermore, 
scientific bacteriologic ex- 
minations of the secretions 
of the genital tract will 
enable us to diagnose defi- 
nitely the provocative factor in conditions which might otherwise remain 
obscure. We are enabled to determine also the specificity, sterility or 



Fig. 102. — Coplin's Method of Indexing and Preserv- 
ing Slides. 



m 



collection; and improper technique 



NO. 473. JvfRS. S. R. .JULY 10,J90€. 


TISSUE FROM UTERIJ^E BODY. 


E4TH. MAG. HYPERTROPHIC GI^NDUly^R EH)0METR1TIS. 




'-^--Tl 






■iiiirr'iriir"'"'"'* ■ 






MP \ 















Fig. 103. — Same as Fig. 102. Folded with SUde 
Enclosed. 



Il6 GYNECOLOGY. 

virulence of inflammatory accumulations and thus become better quali- 
fied to advise and institute proper methods of tieatment and to inter- 
pret, to a certain degree, the prognosis 

66. Parasites, both of animal and vegetable origin, as in all other 
cavities of the body, are found in the genital tract. Of course, here, as 
elsewhere in the body, bacteria or vegetable parasites preponderate and 
are the most provocative of harm. In health, micro-organisms inhabiting 
the genital canal are limited to the structures of the vulva and the vaginal 
canal. Furthermore, even in this part of the genitalia, they are found in 
minimum numbers and attenuated in virulence. The uterus and Fallo- 
pian tubes are normally free from bacteria. The special organism culti- 
vated and described by Doderlein is found more or less constant in the 
vaginal canal and has been termed the acid vaginal bacillus of Doderlein. 
It is said to generate lactic acid and is a rod-shaped bacillus of the ana- 
erobic type. Its discoverer believes it to be a protective force against the 
invasion and action of pathogenic germs. He further believes that even 
if pathogenic bacteria gain entrance to the vagina their virulence is atten- 
uated by the presence of this germ. This micro-organism flourishes in the 
normal acid secretion of the vagina, and if the acidity of the vaginal se- 
cretion is destroyed it disappears and other bacteria flourish. It has 
been demonstrated by Stroganoff that micro-organisms are more numerous 
in the vagina preceding and following menstruation. It has been dis- 
covered that the infectious properties of bacteria are diminished as they 
ascend the vaginal canal and approach the cervix. In the newborn the 
vaginal canal is entirely bacteria free, but soon after birth their presence 
can be demonstrated. In the normal individual, according to Kronig, 
Menge, and Whitridge Williams, it is not possible for bacteria to exist long 
in the healthy vaginal secretion. Kronig demonstrated the germicidal ac- 
tion of vaginal secretion by introducing various organisms into the vagina 
of a normal individual. At the end of two days the vagina became entirely 
bacteria free. Streptococci were the first to succumb, staphylococci 
and pyocyanei living twice as long. During pregnancy it is asserted that 
the acidity of the vaginal secretion is increased and that bacteria are not 
present. Williams, in ninety-two pregnant women, found the skin 
staphylococcus twice, never the streptococcus. Kronig, in forty-eight 
pregnant women, did not find any. From extensive observations it is 
asserted, therefore, that pyogenic bacteria, when found in the puerperal 
genital tract, have been introduced from without. From a bacteriologic 
standpoint the healthy genital canal can be separated into three portions: 
the inferior portion, comprising the vulva and vagina to the cervix, 
contain bacteria; the middle, comprising the cervical canal between 
the external and internal os, as a rule, is free from bacteria; while the 
remaining portion, formed by the uterus, tubes, and ovaries, is entirely 
free from germs. Menge, in his investigations of uteri removed in Zwei- 
fel's clinic, was not able to cultivate germs on any ordinary culture media. 
The external os can be said to be the boundary line between that part oE 
the genital tract containing micro-organisms (vulva and vagina) and the 
part bacteria free (uterus, tubes, and ovaries) . The vulva and the vaginal 



MICROSCOPIC EXAMINATION. 1 1 7 

canal always contain bacteria, and Edgar found in twenty-eight pregnant 
women and two parturient women pyogenic bacteria present in 40 per 
cent. Natvig believes that when pyogenic cocci are found in the normal 
vulva and vaginal secretions, they exist as saprophytes. Under favorable 
conditions, such as have been mentioned, they may multiply, become viru- 
lent and invade the structures higher up. 

67. Natural Agents of Immunity. It has been demonstrated that 
parasites of many varieties, both animal and vegetable, are found more or 
less constantly in the lower portion of the genital canal in the normally 
healthy woman. They are present, however, only in small numbers and 
with attenuated specificity. This is because nature provides natural 
agents of protection or immunity. The protective powers of the normal 
genital canal are: i, the acid secretion of the vagina which is decidedly 
inimical to pathogenic bacteria; 2, the dense arrangement and phagocytic 
action of the v>^all of stratified epithelium lining the vagina which is also 
hostile to invading micro-organisms; 3, the plug or coagulated secretion 
commonly found in the os externum, which, while not truly germicidal, 
acts as a barrier against the entrance of germs into the uterine cavity 
and structures above; 4, the restraining and destructive influence exerted 
by the bacillus of Doderlein against invading pathogenic bacteria which 
has been mentioned. 

Therefore it may be asserted that so long as the vaginal epithelium 
remains healthy and intact, the natural secretions normally generated and 
the vaginal bacilli present, pathogenic bacteria may be found, but their 
excessive production is inhibited and their destructive influence allayed. 

68. Loss of Protection. Certain conditions alter the normal acid 
secretion of the vagina, rid the canal of its protective micro-organisms, and 
change the epithelial wall. This permits the proliferation of infectious 
micro-organisms and the generation of their poisons. Traumatisms pro- 
duced by manipulation, rough examinations, raw surfaces left by opera- 
tion, and injuries resulting from labor afford gateways for the introduction 
of infectious germs into the absorbing tissue tracts. The natural bac- 
tericidal secretion of the vagina is rendered neutral or alkaline or wholly 
destroyed by increased discharge from above, such as takes place during 
menstruation, during parturition, and in alternations of general health. 
Repeated examinations and persistent douching also destroy the antiseptic 
properties of the vaginal canal. 

69. Parasites. I have already indicated that parasites of all varieties, 
both animal and vegetable, are found in the genital tract. I stated that 
the vegetable were the most powerful for harm. The following table 
classifies and shows the varieties of parasites most frequently found: 

Vegetable (Bacteria). 

Staphylococcus pyogenes aureus. Smegma bacillus 

Staphylococcus pyogenes albus. 

Streptococcus pyogenes. Bacillus typhosus. 

Bacillus pyocyaneus. 
Gonococcus. Bacillus aerogenes capsulatus. 



ii8 



GYNECOLOGY. 



Bacillus coli communis. 
Bacillus tuberculosis. 
Spirocheta pallida. 
Organism of chancroid. 



Pediculosis pubis. 
Ascaris scabiei. 
Oxyuris vermicularis. 



Bacillus diphtheria. 
Pneumococcus. 
Diplococcus of Siegelman. 



Animal. 



Ascaris lumbricoides. 
Taenia echinococcus. 



70. Staphylococcus. The staphylococcus pyogenes aureus is perhaps 
the micro-organism most commonly found in localized suppurative pro- 
cesses, and, according to Coplin, Curry found it present in fifty-two of one 
hundred and fifteen abscesses. The staphylococcus pyogenes albus was 
present in twenty-nine. (Fig. 104.) The tendency of the staphylococcus 
is to cause local suppurative lesions, although it may produce general 
pyemic infection and fatal septicemia. I recall one case of fatal staphy- 
lococcemia in which pure cultures of staphylococci were found in the 
blood following a plastic operation on the perineum and cervix. This 
germ is found singly, in pairs, in fours, and in short chains, but generally 





Fig. 104. — Staphylococcus Pyogenes Aur 
eus. From Pure Culture in Bouillon. 
(Zeiss, 2 mm., Oc. c.) 



Fig. 105. — Streptococcus Pyogenes. 
Culture in Bouillon. (Zeiss, 
Obj., Oc. c.) 



From 



in irregular clusters or grape-like bunches. It grows in all ordinary 
culture media at a temperature between 20° C. and 40° C. It liquefies 
gelatin rapidly and in the process of growth the colonies fall to the bottom 
of the medium, assuming a bright orange yellow color, hence its name. 
The culture colonies are at first small and of a white hue, but by the third 
day they assume the characteristic golden-yellow or orange color. The 
staphylococcus stains by all the common anilin dyes, but does not respond 
to Gram's method. The staphylococcus and its kin are perhaps the most 
frequent cause of local inflammation and suppuration of the uterus and its 
appendages and of the pelvic peritoneum. A special feature of this germ 
is its strong attractive chemotactic influence upon leukocytes, particularly 
the polynuclear cell. In two thousand and ninety-eight cases of purulent 
salpingitis three hundred and seventy-four were found to be due to puer- 
peral septic infection, mostly of staphylococcic origin. 



MICROSCOPIC EXAMINATION. 



119 



71. Streptococcus. The streptococcus pyogenes generally occurs 
in chains. It is the most virulent of all the pyogenic cocci and measures 
one-half to one micron in diameter. (Fig. 105.) It grows well at a tempera- 
ture of from 30° C. to 40° C, but does not grow readily below 20° C. and is 
killed in ten minutes at 52° C. It grows on all common culture media, 
appearing as small elevated circular colonies of a grayish-white color. 
It does not liquefy gelatin. The streptococcus stains with the common 
anilin dyes and is positive to Gram's method. This germ is found in 
spreading inflammatory processes, with or without suppuration; in 
serious phlegmonous and erysipelatous conditions and suppurations; and 
in serous membranes and joints; also in malignant endocarditis and 
suppurative periostitis. It is found in inflammatory disease of the 
mucous membrane, particularly of the throat, where it causes a pseudo- 




FiG. 106. — Secretion from Gonorrheal Vaginitis, Showing the Gonococci Both Within 

and Without the Pus-cells. 

a. Pus-cell Containing Gonococci; &, Pus-cell Undergoing Dissolution; c, Large Epithelial Cell. 

diphtheritic inflammation. In puerperal peritonitis it is found in a 
condition of purity. This organism is undoubtedly the most frequent 
cause of puerperal septicemia. The streptococcus is less local in its action 
and far more virulent than the staphylococcus. In septic peritonitis and 
puerperal septicemia the organism is usually conveyed to the vaginal canal 
or uterus from without. It is transported from the vagina or the uterus 
to the pelvic peritoneum through the lymph channels, blood-vessels, 
and by penetration of the uterine wall. The late Dr. Pryor asserted that 
the passage of this germ through the uterine w^all should be counted by 
hours and not days. Sections of puerperal septic uteri demonstrate that 
Dr. Pryor was not incorrect in this assertion, for in nearly all cases the 
organism can be recognized microscopically throughout the tissues of the 
uterus. Doderlein, in his investigations of the vaginal secretions of nearly 
two hundred women, found only one-half normal. The remainder were 
bacteriologically abnormal. In 10 per cent, of the normal cases the 
streptococcus pyogenes was present, and inoculations with the secretions 



I20 GYNECOLOGY. 

from 50 per cent, of these revealed that they were pathogenic for animals. 
Secondary abscesses in the lymphatic glands are more frequently caused 
by streptococci than by staphylococci. However, the virulence of the 
streptococci varies. 

72. Gonococcus. The gonococcus was first described by Neisser in 
1879, and later cultivated in solidified serum by Bumm and others. It 
has been determined definitely to be the specific cause of gonorrhea. The 
gonococcus under the microscope resembles in appearance two coffee- 
beans placed side by side, with an unstained oval interval. Sternberg 
applied the term ''biscuit-shaped" coccus. (Fig. 106.) Irregular and 
degenerative forms of the germ are seen, however. This germ is some- 
times difficult to cultivate on artificial culture media. (Fig. 106.) It 
grows slowly on human blood serum, acid urine agar, blood-smeared agar 
or on Wertheim's media, appearing, at the end of twenty-four or forty- 




FiG. 107. — Secretion of Simple Vaginitis, Showing Various Forms of Organisms Found 
and Preponderance of Epithelial Cells, 
a, Bacilli; b, Streptococci; c, Staphylococci; d, Pus-cell. 

eight hours after inoculation, as small, irregular, rounded colonies of a 
grayish-yellow color. The margins of the colonies are undulated and 
sometimes show small projections. Colonies vary in size and tend to re- 
main separate. They reach their maximum size on the fourth or fifth day 
and, according to Muir and Ritchie, die on the ninth day or earlier. 
The germ stains readily with the basic anilin dyes, but does not stain by 
Gram's method. The gonococcus is found in large numbers in pus of 
acute gonorrhea, both in the male and female. For the most part, it is 
contained within the leukocytes. In the earlier stages it is also found 
outside the pus-cells, but when the discharge is wholly purulent the greater 
portion are found within the pus-cells. Harmsen, in examining gon- 
orrheal secretion, found that in the early stage the discharge was of a 
catarrhal and slightly purulent character, composed of leukocytes with 
a few epithelial cells and no gonococci. As a rule, gonococci appear a 
few days after the onset, but as the disease advances, the leukocytes and 



MICROSCOPIC EXAMINATION. 121 

cocci disappear and are replaced by granular epithelial cells and the 
organisms normally found. Therefore, the absence of the germ in the 
first stage of the discharge is significant, as well as in the last stage. Micro- 
scopic examinations should begin early and be made daily until the germ is 
found. The absence of the gonococcus and the reappearence of the epi- 
thelial cells and organisms normally found indicate that the disease is pro- 
gressing toward cure. Gonococci are also found in purulent secretion 
of gonorrheal ophthalmia and throughout the genital tract when these 
organs are the seat of Neisserian infection. The tendency of the organ- 
ism is usually to remain and cause local genital lesions. It is not re- 
sponsible for disseminated genital infections alone, but is responsible also 
for generalized or systemic lesions, and has been found in pure culture in 
the blood. Gonococcemia usually results from infections of the genito- 
urinary organs, but cases have been recorded where blood infection has 
occurred from gonorrheal ophthalmia. Cases of endocarditis, endarteritis, 
suppurative arthritis, and general pyemia have resulted from absorption 
of the organism. The gonococcus is, unfortunately, found present to an 
alarming degree. In the female it is undoubtedly the most destructive of 
all the pyogenic cocci. When once implanted on the mucosa of the 
female genital tract, it rarely, if ever, is eradicated. Sanger, in a series of 
nineteen hundred and thirty cases, reports two hundred and thirty suffer- 
ing from gonorrheal infection. A committe appointed by the American 
Medical Association found that in pelvic disorders of women requiring 
surgical interference 40 per cent, were of specific diplococcus origin. 
In the gynecological wards of Jefferson Medical College Hospital one in 
5 or 20 per cent, of operations performed are for lesions resulting from 
the action of the gonococcus. Andrews, discussing the etiology of salpin- 
gitis from a series of statistics collected from twenty-eight sources, shows 
that in six hundred and eighty-two suppurative tubes the gonococcus 
was found present one hundred and fifty-five times in three hundred and 
eight cases in which micro-organisms were demonstrated. In three 
hundred and seventy-four the pus w^as sterile. He believed that many of 
these were primarily of gonorrheal origin. Kleinhaus, in two hundred 
and eighteen pus tubes, found the gonococcus present seventy-four times. 
The large number of sterile tubes found was explained by the fact that 
the gonococcus disappears early from pus. It is, moreover, extremely 
difficult to demonstrate the micro-organism in the tubal wall. However, 
the gonococcus does not always disappear from the contents of the pus 
tubes early, because cases have been reported of operation on old-standing 
pus tubes followed by suppurative peritonitis in which pure cultures of 
gonococci were obtained. The gonococcus, while violent and destructive 
in action, is perhaps the most prolific cause of chronically invalided 
women as well as the causative factor in destroying the structure of the 
uterine mucous membrane, rendering it unfit for the lodgment, main- 
tenance, and successful maturation of a fertilized ovum. It is also pro- 
ductive of great harm in the appendages of the uterus (the tubes and 
ovaries) working such changes in these organs as to demand their total 
sacrifice or causing such structural alterations as to prevent the proper per- 



122 GYNECOLOGY. 

formance of their especial functions. However, despite the virulent in- 
fluence which the gonococcus exerts upon the generative organs of women, 
it rarely causes death. It is frequently responsible for violent attacks of 
peritonitis with alarming symptoms, but the inflammatory changes usu- 
ally remain localized and do not spread as infections of this membrane 
do when caused by the staphylococcus, or, more particularly, the strep- 
tococcus. This is due to the fact that gonococci find a natural habitat 
and favorable nutrition in the cells and fluids of the mucous membrane 
lining the genital tract, particularly the cervix and Fallopian tubes, whereas 
the endothelial cells of the peritoneum and the peritoneal fluid are, to a 
certain degree, hostile and destructive to this germ, thus destroying many 
and driving others into a localized field of battle. 

Gonorrheal infection in little girls is not an uncommon affliction. Its 
conduct may be just as serious as in the adult. If it makes its appearance 
in an institution for the care of children, the entire population may become 
infected, for it spreads as violently as scarlet fever. The first considera- 
tion, therefore, should be early isolation. The infection may he conveyed 
by servants. It is frequently conveyed by rape. W. Travis Gibb, in his 
association for fifteen years with the New York Society for the Prevention 
of Cruelty to Children, has examined eight hundred girls, ranging in age 
from eight months to sixteen years, on whom rape and other serious crimes 
had been committed. He found that almost 13 per cent, of all these 
children suffered with venereal disease, 81 per cent, had gonorrhea, 2.5 
per cent, had chancroids, and a small number of the cases examined had 
syphilis. 

Gonorrheal infection in the female is a highly destructive disease, and 
J. T. Johnson says that no affliction of modern times has caused so much 
mortality, mutilation, and mental and physical suffering as gonorrhea 
has indirectly. 

It is generally admitted to be the most widespread and universal of 
diseases. Morrow believes that no disease has such a muderous in- 
fluence on the offspring as syphilis; that gonorrhea overshadows syphilis 
as a social peril, and no disease has a more destructive influence on the 
health and procreative function of women. 

Bad as gonorrheal infection is, it is a question whether its evil effects 
have not been overestimated. The common belief that a man once in- 
fected is never free and is likely to infect his wife cannot be accepted fully. 
Erb, who made an exhaustive statistical study of the subject, is forced to 
this opinion. He investigated carefully the sexual histories of two- 
thousand male patients — principally of the middle class — and found that 
48.5 per cent, had had gonorrhea. The wives of four hundred of these 
patients confessed to having had gonorrhea some time previous to marri- 
age. Of these, three hundred and seventy-five, or 95.75 per cent., had 
never suffered from any pelvic infection that could have been of gonorrheal 
origin. Only seventeen, or 4.25 per cent., had had what were probably 
gonorrheal infections. As to the influence of ante-nuptial gonorrhea on 
fertility, among three hundred and seventy couples in this class, 68 per cent, 
had two or more children; 25 per cent, had four or more children; and but 



MICROSCOPIC EXAMINATION. 



123 



12 per cent, were childless. In the latter, some other cause than gonorrhea 
was evident. 

73. Bacillus coli communis is found present normally in the in- 
testinal canal. Morphologically it resembles the typhoid bacillus. The 
colon bacillus is usually found in mixed infections, though pure infections 
by this organism occur. Andrews, in his bacteriologic statistic study of 
pus tubes, found that the colon bacillus was present in 2.5 per cent. 
(Fig. 108.) This germ is frequently responsible for inflammatory dis- 
orders of the intestinal canal and suppurative processes in the peritoneal 
cavity. If is often found in inflammation of the urinary passage, such as 
cystitis, pyelitis, and pyelonephrosis. Colon suppuration of the organs 
in the pelvis occurs, and Reed says that it is responsible for a certain per- 
centage of cases of ovarian abscess. He claims that the contiguous sur- 
face of the diseased organ as it becomes adherent to the bowel affords an 
opportunity for the introduction of the germ. Roberts states that sup- 





FiG. 108. — Bacillus CoK Communis. 
From Pure Culture in Bouillon. 
(Zeiss, 2 mm. Obj., Oc. c.) 



Fig. 109. 



-Bacillus Tuberculosis. (Zeiss, 
2 mm., Oc. c.) 



puration of ovarian cysts, especially after twisting of the pedicle and the 
resulting adhesions to the bowel, have a similar explanation, and many 
suppurative infections of the abdominal incision can be traced to this germ. 
74. Bacillus tuberculosis, discovered by Koch in 1882, is rod-shaped, 
I 1/2 to 3 1/2 microns long, 1/4 to 1/2 micron thick. It grows readily upon 
solidified blood serum and glycerin agar. It develops slowly, not appearing 
for two or three weeks after inoculation. (Fig. 109.) The colonies are of a 
creamish color and somewhat granular. This becomes more marked as the 
growth ages, and, according to Coplin, the surface of the colony takes on 
a bread-crumb appearance. The bacillus stains, with most of the basic 
anilin dyes and by Gram's method. It takes the stain slowly but se- 
curely, and is with difficulty decolorized. It resists strongly the de- 
colorizing action of mineral acids in common with certain other organisms 
belonging to the acid-fast bacteria. Primary tuberculosis of any part of 
the genital tract is rare, though tuberculous lesions may occur in any 
portion. The Fallopian tubes are the organs most frequently infected, 
and next in order of frequency are the uterine body, ovaries, vagina, cervix 



124 GYNECOLOGY. 

and vulva. Tuberculous infection of the vulva and vagina is rare, and is 
usually secondary to infection from the uterus. Tuberculosis of the vagina 
is frequently associated with or is secondary to tuberculous inflammation 
in other portions of the genito-urinary tract, as the bladder, bowel, peri- 
toneum, or distant organs, as the lung or joints. Primary vaginal tuber- 
culosis, however, has been reported by Friedlander. It has been 
demonstrated that the freedom of the vulva and vagina from tuberculosis 
is due to the resistance of the squamous epithelium to bacterial invasion. 
Tuberculosis of the vulva and vagina (lupus), while extremely rare, is a 
very destructive disease. Tuberculous infection of the vulva may extend 
over a period of many years. In one case under my observation in the 
terminal stages the entire vulva was totally destroyed, establishing fistulous 
communication between the vagina and rectum and vagina and bladder. 
I have frequently seen rectovaginal fistulae as a result of tuberculous disease 
of the rectum. Tuberculous infection of the uterus also is rarely a pri- 
mary disease : it is generally associated with or is secondary to tuberculous 
lesions in the tubes, peritoneum, or some other structure of the body. 
Tuberculosis of the uterus and the organs above occurs with greater 
frequency than is clinically observed, as careful postmortem examinations 
of individuals dying from pulmonary tuberculosis has proved, yet Martin, 
in sixteen hundred examinations of the uterine mucous membrane, found 
only twenty-four instances of tuberculous lesions in the uterus. Accord- 
ing to Spaeth, tuberculous infection of the cervix constitutes about 5 
per cent, of the cases of genital tuberculosis in women. The Fallopian 
tubes are the most frequent seat of genital tuberculosis. In a total of 
one hundred cases of pyosalpinx collected by Andrews 10 per cent, were 
tuberculous. The infection is usually secondary to tuberculous foci 
elsewhere- in the body. In primary tubercular salpingitis the baciUi are 
introduced from without, and attack the tube by ascending the genital 
canal. Secondary infection of the tube usually results from tuberculous 
peritonitis, but it may also result from metastatic deposition through the 
blood- or lymph-vessels. Infection may be conveyed by contiguity of 
structure from a tuberculous ulcerating intestine to an adherent tube. 
Meyer reports fifty-seven cases of primary tuberculous tubal disease out 
of sixty-seven cases of genital tuberculosis. Orthmann states that pri- 
mary tubal tuberculosis occurs in 18 per cent, of all cases of genital 
tuberculous infection in women. Rosthorn, in eighteen hundred and 
fourteen cases of inflammatory disease of the tubes, found tuberculous in- 
fection to be the exciting cause of twenty-nine. Tuberculous infection, 
particularly of the tubes, occurs in young children and in virgins. All 
cases of tuberculous peritonitis, however, are not necessarily associated 
with tuberculous inflammation of the tubes or uterus. I have operated on 
several cases of tuberculous peritonitis in young women, and in most of 
these careful observation failed to reveal any marked tuberculous pro- 
cess in these organs, although some of the cases were of long duration. 
It is stated by certain investigators that pre-existing gonorrheal infec- 
tion of the tube predisposes to tuberculous disease. Infection of the 
ovaries by the tubercle bacillus is exceedingly rare, one or two cases of 



MICROSCOPIC EXLA.:\nNATIOX. 1 25 

primary ovarian tuberculosis having been recorded, but in the vast major- 
ity of cases it is secondary to tuberculous infection of the Fallopian tubes, 
peritoneum, and intestines. In forty-eight cases of ovarian tuberculosis 
Orthmann traced the infection to the tubes in twenty-six and the perit- 
oneum in twenty-two. Infection of the peritoneum by the tubercle 
bacillus occurs in men, women, and children. The disease may occur in 
the acute miliary, caseating, or chronic fibroid form. It is most frequent 
in" women, and the relative frequency given by different observers is 
from 50 to 98 per cent; usually occurring in young women between 
twenty and thirty years of age, though the infection occurs at all ages. 
Tuberculous peritonitis was found two hundred and eighty-four times in 
thirteen thousand four hundrd and twenty-two autopsies studied by 
Grawitz and Brum, and the Mayos, in five thousand six hundred and 
eighty-seven operations, found it present eighty-nine times. Osier found 
that in abdominal operations for tuberculosis, laparotomy w^as performed 
twice as often in females as in males. An interesting feature of tuber- 
culous infection of the peritoneum is the unusual occurrence of extensive 
lesions in other portions of the body. 

Tuberculosis of the placenta is not an uncommon affection. Schmorl 
and Geipell report twenty such cases in patients suffering with various 
forms of advanced phthisis. 

75. Syphilis and Chancroid. Chancroid usually makes its appear- 
ance upon one labia; often upon both. It is seen quite commonly as an 
irregular, excavated ulceration just within the fourchette or posterior 
vaginal commissure. Frequently multiple from contact infection, the 
lesion presents an irregular, sloughing ulceration with ragged, overhanging 
edges, and a granular, worm-eaten floor covered with purulent secretion. 
In the majority of instances the malady is associated with infection of 
the inguinal lymphatic glands. Infection of the lymphatic glands is one- 
sided, as a rule, but both sides may be involved. These glands usually 
become greatly enlarged, fixed, and inflamed; they often undergo 
suppuration, forming the typical venereal bubo. 

Syphilis has long been regarded as microbic in origin and many in- 
vestigators claim to have discovered the specific organism of this disease. 
Lustgarten, in 1884, described an organism which was regarded by the pro- 
fession as the provocative agent, but this germ has never been cultivated 
out of the body and now is not considered to bear any etiological relation 
to syphilis. Many of the other views and assertions concerning the eti- 
ology of syphilis are now regarded as of historical interest only. Since the 
discovery of the spirocheta pallida, or treponema pallidum, by Schaudinn 
and Hoft'mann in 1905, the convictions of the profession as to the microbic 
origin of syphilis are more firmly grounded. The failure of this germ to 
comply with Koch's law, or the conditions demanded by modern science 
to prove that a special germ is the specific cause of an infectious disease, 
still leaves some doubt as to the true etiological relation this organism 
bears to syphilis. Xevertheless, the uncertainty can have little weight, 
for the evidence of the responsibility of this germ for the production of 
this affliction is practically complete. The spirocheta pallida has been 



126 GYNECOLOGY. 

found in spreads taken from all lesions of early syphilis, such as chancre, 
secondary skin eruptions, and mucous patches, as well as in the blood, 
before, during, and after the appearance of early syphilitic signs. It has 
also been found in hereditary lesions, in the fetus, and sections taken from 
the internal structures; also in syphilitic lesions of inocculated apes. 
The organism appears as a spiral body. It measures from 6 to 12 microns 
in length and about one-fourth of a micron in thickness. It is composed of 
of 6 to 14, or more, steep turns or spirals. The ends are drawn out sharply, 
and frequently are provided with long, thready flagella. The special 
stain of Giemsa will enable one to recognize the parasite easily in carefully 
prepared spreads. In 1909 Burri pointed out the fact that bacteria were 
not stained by India ink, and, as a result, the presence of micro-organisms 
in a thin layer of ink could be recognized by the presence of clear areas in a 
dark field. This method is admirably adapted to staining the syphilitic 
spirocheta because of its simplicity, the cheapness of the materials used, 
and the ease with which the organisms are recognized in the microscopic 
field. Moreover, the ordinary commercial India ink, such as Guenther's, 
or Higgins' waterproof ink, may be used. Levaditti's method affords the 
best means of demonstrating the treponema in the tissues. 

Syphilitic infection in woman may conduct itself just as it does in man 
and leave traces of its destructive action in all the vital systems of the 
body. Most observers agree, however, that syphilis in woman runs a 
milder and more concealed course. Women with advanced tertiary lesions 
frequently are unable to recall any annoyance of the primary or secondary 
stages; but this is not the universal rule, and in many cases the disease 
pursues a course, as it does in man, with all the primary and secondary 
manifestations. 

The inital lesion of chancre usually appears in some portion of the 
vulva. It is found frequently in the region of the fourchette; appearing 
occasionally on the cervix uteri; and, still more rarely, may be found 
on the lips or nipples. 

The most common type of syphilis met in women is the secondary or 
tertiary lesions of the vulva, manifested by vegetations, condylomata, and 
gummatous formations. The accompanying illustration portrays a case 
of the extensive syphilitic infection of the vulva of a young married woman, 
eighteen years old, who came under my observation in the Jefferson Med- 
ical College Hospital. Tertiary lesions in the form of gummata are not 
uncommon in the uterus and its appendages. A gumma in the uterine 
wall might be confounded with fibroid tumor. It is important to differen- 
tiate chancroidal infection of the vulva from the initial lesion of syphilis 
in these structures. The soft sore appears as an irregular excavated ulcer 
with unequal overhanging edges, and a granular, angry, worm-eaten 
floor covered with purulent exudate. Frequently the lesion is multiple, 
but never hard nor indurated. The chancroidal bubo is generally uni- 
lateral. It is large, immobile, painful, tender, and discolored. It usually 
suppurates. The chancre appears as a small, roundish, grayish ulcer 
with hard, well defined, indurated edges. It is covered with a thin sero- 
sanious secretion, and surrounded by an area of hard edema. The 




Fig. iio.— Vulvar Vegetations from Sypmiuic 1 



ntection. 



MICROSCOPIC EXAMINATION. 1 27 

period of incubation and appearance of secondary manifestations will also 
aid in the differentiation, as well as the bilateral multiple enlargement of 
the inguinal lymph glands which do not attain large size, are movable, 
and do not tend to suppurate. Moreover, lymphatic gland enlargement 
is frequently found in other portions of the body. Treponema in the 
secretion of the sore will confirm the diagnosis and the therapeutic test 
will also aid in the differentiation. It is important to keep in mind the 
possibility of a mixed infection, in which case the chancroid will in a short 
time assume the character of a chancre. Treponema is here classed with 
the vegetable parasites, although there is doubt as to whether this organism 
belongs to the vegetable or animal kingdom. 

76. Bacillus typhosus may be found in any part of the genital 
tract during typhoid infection, and for months, or even years, after the 
fever has subsided. It is found in acute infectious inflammations of the 
endometrium, and Pfannenstiel reported three cases of post-typhoid 
ovarian abscess. Several other cases have been reported. The typhoid 
bacillus has been found in suppurating ovarian cysts several months 
after the primary typhoid infection. It is probable that the bacilli reach 
the ovarian structure by passing through the intestinal wall. Typhoid in- 
fection of the vulva and vagina also occurs, and, according to Keen, the 
lesions usually occur as distinct vulvar gangrene and gangrenous ulcera- 
tions in the vagina. He collected eight cases, seven of which were in 
young persons from seventeen to twenty-seven years of age, and one of 
thirty-four years. In six of the cases there was gangrene of the labia, ex- 
tending sometimes to the perineum and thigh. Fistulous communica- 
tions between vagina and bowel were established. The gangrenous ulcers 
were commonly located on the posterior vaginal wall. Ulceration of the 
anterior vaginal wall is also reported, with the formation of vesico- 
vaginal fistula. In some of the cases great distortion of the vagina de- 
veloped from cicatrization, and in one case complete occlusion, resulting 
in retention of menstrual fluid which required operation for its liberation. 
Keen reported a patient under his observation with both rectovaginal 
and vesicovaginal fistulae. Typhoid infection of the uterus during preg- 
nancy frequently occurs and generally results in the expulsion of the fetus. 
Typhoid bacilli have been found in the placenta, and Keen studied a case 
reported by Freund and Levy in which spontaneous abortion occurred at 
the fifth month. The patient was in the declining stages of typhoid in- 
fection. Bacilli were found in the blood of the placenta, in the spleen, 
and in the heart of the fetus. Similar cases have been reported. 

77. Smegma bacillus normally inhabits the secretions of the ex- 
ternal genitals, and may be found in the urine associated with particles of 
detached smegma. The germ is not pathogenic. Morphologically it 
resembles somewhat the tubercle bacillus, but is shorter and differs tinc- 
torially in that it is not an acid-fast bacillus, and, therefore, is readily 
decolorized by the mineral acids. 

78. Bacillus pyocyaneus, a short, rod-shaped, motile organism 
which measures i to i 1/2 microns in length by 1/2 micron in width, 
grows readily in nearly all culture media at a temperature of 20° C, lique- 



128 GYNECOLOGY. 

fying gelatin, and in the process of growth the colonies assume a greenish 
hue. It is found in green pus and in the discharge of the intestinal 
disorders of infancy. It has been found in suppurative peritonitis, 
otitis media, endocarditis, and other affections. 

79. Bacillus aerogenes capsulatus is a gas-producing bacillus, 
measuring 3 to 6 microns in length and i to i 1/2 in thickness. 
It is truly anaerobic, grows in all culture media in chains of three 
and four, and generates gas and acid in the process of development. 
It has a distinct capsule. The germ has been found in emphysematous 
gangrene, in cases of emphysematous vaginitis, and in the uterus in puer- 
peral septic infection. The distention of the puerperal uterus with gas, 
which sometimes occurs (physometra) , is, no doubt, due to the presence 
of this micro-organism. 

80. Diphtheria Bacillus. Infection of the genital canal with Klebs- 
Loeffler bacillus, while rare, occasionally occurs, and cases of diphtheritic 
infection of the vulva, vagina, and uterus are reported. Infection gener- 
ally occurs during the puerperium and is implanted on injured tissues. 
The infectious process presents the same pathologic anatomy as noted 
when occurring in the throat, and responds likewise to the administration 
of antitoxin. The poison, when implanted upon abraded structures, 
rapidly generates the characteristic false membrane, which hastily spreads 
over the entire vagina and even into the uterus and tubes. Diphtheroid 
infection frequently results from the presence of the streptococcus and other 
pathogenic bacteria, particularly the former, following labor, but the mem- 
brane formed by the streptococcus develops in patches and is confined to 
abraded surfaces (Edgar) ; therefore, if the entire genital tract is covered 
by the pseudo-membrane, true diphtheria is suggested. Infection of the 
genital tract by the bacillus of diphtheria is usually conveyed by the attend- 
ing physician, and it follows, therefore, that no case of labor should be 
attended by men who are at the same time caring for patients suffering 
with diphtheritic infection. 

81. Pneumococcus. The diplococcus of Frankel has been found 
in suppurative conditions of the female genital tract, particularly of the 
Fallopian tube. Andrews, in his cases collected from literature, found 
the pneumococcus present fourteen times, thirteen times in pure culture 
and once mixed with other germs. Pneumococcic infection of the genital 
canal, however, does not bear any definite relation to pneumonia. The 
infection usually has been introduced from without into the lower genital 
canal. The pneumococcus has been found in suppurative processes of 
the ovary; it has been reported to have been collected in pure culture 
from an ovarian abscess. 

82. The diplococcus of Siegelman occurs in pairs and somewhat 
resembles the gonococcus. It is smaller and is further difi^erentiated 
from the gonococcus in that it accepts Gram's stain. The germ was 
discovered by Siegelman in several cases of pruritus vulvae in which there 
was no other demonstrable cause. Siegelman attributes, therefore, 
the so-called cases of idiopathic pruritus vulvae to the action of this coccus. 

83. Collection of the fluids and secretions is necessary to make 



MICROSCOPIC EXAMINATION. 1 29 

a positive diagnosis of certain infectious conditions and to determine 
the character of the specific infectious agent present, and they must be 
subjected to careful bacteriologic analyses. Microscopic and bacteri- 
ologic examinations of secretions and fluids from the genital tract, 
however, should not be the only bases considered in making a diag- 
nosis, but should be regarded as an additional resource for establish- 
ing the diagnosis. Bacteriologic examinations of the secretions can be 
made with carefully prepared cover-glass spreads from the vulva, vagina, 
and cervical canal, and the orifices of the various communicating glands, 
such as Bartholin's and Skene's. Spreads should also be prepared from 
secretions expressed from the urethra. The preparation of the spreads 
should not be left to the nurse, but should be made by the physician him- 
self. Cover-glass specimens are prepared from the vulva by transferring 
the secretion from the parts with an applicator provided with a small 
swab of sterile cotton or the ordinary platinum needle, the end of the 
needle proper being rolled together in order to afford a larger collecting 
surface. This is applied to the part containing the secretion and then 
transferred to the cover-glass. Specimens may be secured from the 
vagina and cervix in a similar manner, though material from the cervix 
should be obtained after exposing the cervix with a speculum, when the 
secretion can be collected as it escapes directly from the cervical canal. 
It is important in preparing cover-glass spreads to collect secretion from 
the parts most commonly the seat of infection, such as the orifice of the 
urethra, orifice of Skene's and Bartholin's glands, and from the cervical 
canal. In long-standing infections of the cervix the germs are found to 
inhabit the glands; therefore, to demonstrate their presence, the glands 
should be punctured and the contents collected on a cover-glass as they 
emerge at the site of puncture. In infecting culture media inoculations 
should be made with the suspected secretion from the different parts of 
the tract, not one part alone, and several cultures should be prepared. 
It is important in collecting discharges for bacteriologic examination 
that the patient should not receive any antiseptic douche for at least a 
period of twenty-four hours before the collection is made. This proce- 
dure destroys the microscopic value of secretions and, therefore, renders 
examination practically worthless. Cover-glass spreads can also be 
employed in private practice — both in office work and in outside practice. 
The secretions and fluids can be collected also in especially prepared 
glass pipets, the material being drawn into the pipets with a syringe, 
after which the ends of the tubes are hermetically sealed. With the secre- 
tion contained the pipets should be enveloped in cotton or other protect- 
ing material and conveyed to the pathologist for examination. It is also 
always important in preparing cover-glass spreads, cultures, or secretion 
tubes to letter or number each in order to designate the organ from which 
the collections were made. Fluids from cysts are sometimes collected 
and examined microscopically to ascertain their true character, but only 
in hydatid disease can we definitely assert the true nature of the lesion 
by finding the booklets of the parasite. Secretions of the genital tract 
are, as a rule, only collected and examined to determine the presence and 



130 GYNECOLOGY. 

virility of bacteria present, although sometimes particles of benign or 
malignant neoplasms may be discharged, which are collected and studied 
intelligently, but usually only very small pieces of tissue are thus obtained, 
and from these positive microscopic diagnoses cannot be made. More- 
over, sections of material escaping in secretions are generally so altered 
by necrobiotic processes that the recognition of their true character is 
necessarily rendered extremely difficult. 

ANIMAL PARASITES. 

84. Pediculosis pubis or inguinalis, the ordinary crab louse, is 
generally found in the hair of the pubic region, sometimes in the axilla, 
and occasionally in the eyebrows. Careful examination will reveal the 
parasite near the roots of the hairs, with its head downward buried in the 
follicle. The spores will be found deposited on the hair shafts. In the 
pubic region this parasite is responsible for intense pruritus, resulting in 
hyperemia and excoriation from scratching. 

85. Acarus scabiei, the itch-mite, while found on the tender skin 
areas of the body, is frequently present in the skin of the lower abdomen 
and vulva, inducing intense itching with excoriation and abrasions of the 
skin from constant scratching. 

86. Oxyuris vermicularis, the ordinary seat or pin worm, inhabits 
the colon and rectum. From these regions it wanders to the vulva and 
vagina and may wend its way into the interior of the uterus. Fallopian 
tube, and ovaries. Mano, quoted by Andrews, reports a case of a large 
cyst of the ovary and two small cysts of the tube in which were found the 
eggs of this parasite. He believes that the parasite reached the tube 
and ovary by traveling from the rectum, the vagina, and uterus. The 
pin worm is found at all ages, but commonly in children. The parasite 
causes intense pruritus, which is always worse at night, due to its noctur- 
nal migration. From the itching and scratching, excoriations and inflam- 
mation of the vulva result, and even perirectal abscesses may form. 

87. Ascaris lumbricoides, the ordinary round worm of the intestinal 
canal, is the most common animal parasite found in human individuals. 
It usually occurs in children and occupies generally the upper portion of 
the small bowel. From this region they migrate through the various 
channels connected with the alimentary canal, and even penetrate the 
intestinal wall. Cases are recorded where they have completely occluded 
the biliary passages, and traveled through the Eustachian tube and 
projected from the external ear. They have been found in the vagina, 
uterus, tubes, and free in the pelvic cavity. J. H. Koch found the ascaris 
in an abscess in the pouch of Douglas. The portal of entry was through 
a fistulous communication from the rectum. Bizzozero found the ascaris 
in the right Fallopian tube; the parasite had entered the tube by traveling 
through a perforation in the rectal wall. 

88. Taenia eichinococcus, or dog tapeworm, is a parasite in- 
habiting the intestinal canal of the dog and wolf. The adult worm is 
composed of five segments. The first segment is slender and continuous 



BLOOD EXAMINATION. 131 

with the head; the second is the shortest; and the posterior segment, 
the longest, is frequently more than half the length of the parasite. The 
adult worm is not found in the human individual. The larvae of the 
parasite are taken into the alimentary canal of the individual, or in the 
female they may enter also by way of the vagina. When conveyed by 
the alimentary canal the embryos are hatched and these wander into the 
tissues of various organs, forming the hydatid cyst. In Iceland, where 
human beings and dogs live together in closely confined quarters, echi- 
nococcus disease is endemic. The liver is the organ most frequently af- 
fected, being involved in 50 per cent, of the cases. Echinococcus cysts 
may develop in any part of the body. The disease is more frequent in 
women than in men, and Finsen found that in two hundred and forty- 
five cases 70 per cent, occurred in women. In the pelvis the disease 
is usually situated in the cellular tissue of the posterior pelvis and also in 
cellular tissue anterior to the uterine body. Cases have been reported 
where the cysts have developed in the uterine body proper. Hydatid 
disease develops in the Fallopian tube, and Doleris collected from liter- 
ature eighty cases of hydatid disease of the tube, one of which (his own) 
was possibly primary in the tube. Primary echinococcus infection of 
the ovary is rare, though a few cases have been reported. The diagnosis 
of this condition is made positive by finding the hooklets or scolices. A 
cystic tumor containing fluid of comparatively low specific gravity (1005 to 
1012) and nonalbuminous, or presenting only a slight trace of albumin 
and neutral in reaction should be suggestive of echinococcus disease. 

BLOOD EXAMINATION. 

89. The Blood. Systematic and careful examination of the blood 
in certain gynecological conditions will reveal special clinical facts which 
cannot be elucidated by any other means. Gynecological diagnoses, 
however, must be made by utilizing all clinical methods of examination. 
Too much value should not be attached to one plan alone. I feel it 
important to emphasize the fact that superficial blood examination should 
never be made, as the knowledge thus obtained is also superficial, and 
Tof little practical value. Examination should comprise the determina- 
tion of the number and character of red blood cells; the number, character 
and relative proportion of leukocytes; an estimate of the hemoglobin per- 
centage; in certain cases, the presence or absence of parasites; and the 
serum reaction. This plan of examination would meet all practical 
requirements, but a more complete examination, of scientific rather than 
practical interest, would consist in the estimation of the specific gravity; 
the determination of the alkalinity, coagulability, and toxicity; and 
spectroscopic revelations. The methods of collection and the various 
instruments used in examination are fully described in special works on 
hematology, such as Da Costa's, Cabot's, and others. The lengthy 
description of such methods and implements would require too much 
space in a work of this character. 

It is important to recall that all the vital structures and fluids of the 



132 GYNECOLOGY. 

body are profoundly disturbed by various lesions in the pelvis, and, after 
the nervous system, perhaps none more than the blood. From the advent 
of the first menstrual period to the climacteric, a succession of changes 
takes place in this fluid. A reduction in quantity and quality of the blood 
frequently occurs in young girls just before or during the first years of 
menstrual life, giving rise to a primary anemia known as chlorosis or 
green sickness. This condition is frequently responsible for disorders 
of this function. Marked disturbances in the blood are constant in 
pregnancy, and in the various pathological types of this condition. 
More or less blood destruction is observed in women suffering with uterine 
fibroids — particularly of the submucous type. Alterations in the quantity 
and the quality of the blood are constant in malignant disease of the 
genital canal; especially in cases of uterine cancer and chorio-epithelioma. 
Indeed, in the latter condition, the patient may appear almost bloodless. 
It will be found that the revelations of careful blood analyses not only 
aid us in establishing a positive diagnosis and indicate the prognosis, 
but also help us to adopt methods of treatment, either medical or surgical. 
The medical treatment of pelvic disease would not be complete without 
the institution of measures to improve the condition of blood. It is a 
question whether many of the displacements of the uterus or benign pelvic 
affections are not due frequently to blood starvation with a consequent 
loss of muscle tone. This would seem true because it is not unusual to 
see pale, flabby, weak, debilitated women suffering with marked dis- 
placements of the uterus to whom operation offers apparently the only 
method of reHef; yet, after careful rest, restoration of the qualtity of the 
blood, and improvement of the general health, we find the uterus assume 
its normal health and position. The disorders of the menstrual process 
manifested by scanty and painful flow, especially in young women during 
the early period of menstrual life, are commonly associated with some type 
of anemia, particularly chlorotic anemia. It is gratifying to observe that 
measures directed to correct this condition will in the majority of cases 
bring about a healthy performance of this function. As a matter of prac- 
tical surgery, it is decidely important to obtain full knowledge of the blood 
quality before instituting operative measures, because, by the information 
thus gained, the surgeon is better able to determine the relative resistance 
of the patient, the probable character of her convalesence, and the pos- 
sibility of vicious or faulty union of operative surfaces. It is a well known 
fact that in the presence of marked anemia the danger of shock and general 
or local wound infection is much greater; convalesence more prolonged, 
and union more tardy, than when this condition does not exist. I believe 
that many cases of suppuration after operation are due to pre-operative 
anemia and the absence of the elements necessary for rapid and complete 
union. I recall one case of marked anemia due to uterine cancer. 
There was no attempt to repair eleven days after operation, and on the 
removal of the sutures, the abdominal incision gaped wide open allowing 
the intestines to protrude. The statement is justifiable that it is unwise 
to operate when the red blood cells are greatly reduced and the hemoglobin 
below 30 per cent., but, unfortunately, we are sometimes compelled to 



BLOOD EXAMINATION. I33 

interfere when the blood condition is worse than this — frequently with 
unhappy results. 

90. Leukocytes. For diagnosis and prognosis one of the most 
important disclosures of a blood analysis is the number and relative 
proportion of the white cells. An increase of the total number of leuko- 
cytes is always more or less constant in pelvic inflammatory disease. 
Pankow believes that a leukocyte count of 10,000 indicates suppuration 
in the adnexa, if other causes be eliminated. I have come to regard a 
leukocyte count of 12,000, or over, as indicative of suppurative affections 
of the appendages, and rarely have been mistaken. In forty-six cases 
of acute pelvic inflammation I found a leukocyte count to range from 12,- 
000 to 31,000. Da Costa found in thirty-four cases of pelvic abscess, 
ovarian abscess and pyosalpinx an average count of 15,548. Diitzman 
reports 232 gynecological cases in which 2,000 counts were made; in 
ninety of them pus was revealed by this means, when the probability 
of its existence was not made evident by other tests, including palpation 
under narcosis. H. C. Taylor, in thirty-two cases of pyosalpinx, found a 
marked leukocytosis in all. He relies on the polynuclear count as the 
most valuable indication of pus, ranging from 80 to 90 per cent, in fifteen 
cases, and 75 to 80 per cent, in seven cases. There is no doubt that the 
relative percentage of the polynuclear cells is of more importance than 
the knowledge of the leukocyte count alone, in determining the presence 
of suppuration. It is well to remember that the increase in the number 
of the white cells will depend upon the degree and limitation of the sup- 
purative process. If an abundance of the toxic material is absorbed from 
the pelvic lesion and the resistance of the patient is good, the count will 
be high. On the other hand, if the lesion is enveloped by a nonabsorbing 
inflammatory wall, and the resistance of the patient is poor, probably 
the count will be low. In malignant disease, also, the white blood cells 
are increased, but, according to Julliard, this does not take place early. 
When ulceration and necrosis occur in malignancy, leukocytosis develops 
with the absorption of toxic matter from the aft'ected parts. The effect 
of malignant disease on the leukocytes wfll depend on: (i) the position 
of the tumor; (2) its size; (3) the rapidity of its growth; (4) the occurrence 
of metastases; (5) the resisting power of the individual, and (6) the degree 
of necrotic change. In cancer of the uterus, as a rule, the leukocytes are 
slightly increased. In seven cases reported by Cabot, a leukocytosis 
which ranged from 16,800 to 34,000 was observed in five. No decided 
alteration was noted in the number and characer of these cells in the two 
remaining cases. It may be said, however, that malignant leukocytosis 
is generally low and, according to Da Costa, counts of less than 20,000 
are the ordinary rule. Malignant leukocytosis is commonly most pro- 
nounced in sarcoma. 

91. Bacteremia is defined as the presence of micro-organisms in the 
circulating blood. Normally the blood is regarded as bacteria-free, yet 
recent investigations show that even under normal conditions bacteria 
exist in the blood. The condition has been denominated "latent microb- 
ism." This mild bacteremia is wholly consistent with health, because 



134 GYNECOLOGY. 

the bacteria present are small in number and not virulent, and, therefore, 
cannot do harm unless the individual is weakened in resistance and the 
bacteria multiply and become virulent. 

Bacteria found in Blood. A large number of bacteria have been 
isolated from the circulating blood. Among the most important are: 
I. The pyogenic bacteria. 

{a) Staphylococcus pyogenes. 

{h) Streptococcus pyogenes. 

(c) Gonococcus. 

{d) Pneumococcus. 

{e) Diplococcus intracellularis meningitidis. 
Other bacteria found in the blood are: 

Bacillus anthracis. 

Bacillus coli communis. 

Bacillus influenzae. 

Bacillus leprae. 

Bacillus mallei. 

Bacillus pestis. 

Bacillus tetani. 

Bacillus tuberculosis. 

Bacillus typhosus. 
Besides these vegetable parasites, certain animal parasites are found 
in the blood, the most important of which are the malarial plasmodia, 
the embryo of the filaria, and spirilla of Obermeyer. 

92. Blood Culture. The blood secured for bacteriologic examina- 
tion should be aspirated by puncturing a superficial vein which has been 
exposed by an incison, and not by puncturing the vein through the skin. 
Examination of prepared cover-glass films is unsatisfactory. In obtain- 
ing the blood the veins in front of the elbow-joint (median basilic or 
median cephalic) may be selected. The tissues of the part should be 
thoroughly sterilized in order to rid them of the common dermal bacteria. 
According to Da Costa, fluid culture media are preferable to the solid. 
One-half cubic centimeter of blood should be drawn for each culture, and 
about one hundred parts of media to each part of blood should be used. 
A special needle can be secured for withdrawing the blood (Fig. no), 
but in an emergency a sterile antitoxin or hypodermic syringe may be 
employed. 

THERAPEUTICS. 

93. Classification. The treatment of gynecological cases may 
be medical, electrical or surgical; the first being general or local. Natur- 
ally the subject comprises the consideration of preventive medicine and 
the discussion of both palliative and radical measures for the eradication 
of disease or the amelioration of its distressing effects. 

94. Medical Treatment: general or constitutional measures. In the 
investigation of every patient suffering from symptoms which indicate 
genital disease, it is important that the condition and actions of the various 



THERAPEUTICS. I35 

organs of the body should be studied carefully. The disorders of one 
structure of the body should not be treated as if it were not an integral 
part of the whole, incapable of producing disturbing influences on organs 
near or remote; nor having its functions unbalanced by disease in the or- 
ganism without its immediate environment. Renal, hepatic or cardiac 
disease and arteriosclerosis, by increasing vascular tension, disturb the 
menstrual function, causing the unobservant to subject the patient to 
futile local and operative measures. Engorgement of the liver and conse- 
quent obstruction of the pelvic circulation must be relieved by suitable 
measures. Pelvic engorgement from defective cardiac action demands 
measures to increase the activity of the heart's action and so facilitate 
elimination. Increased vascular tension from arteriosclerosis, with or 
without renal lesions, indicates the employment of the iodids and 
nitrites, careful regulation of the diet, the promotion of the secretions 
and the judicious use of baths. If the kidneys are unable to eliminate 
sufficient morbid material, the skin and bowels must do additional work. 
The advent of such conditions is frequently so insidious that the action 
of the kidneys should be determined by a careful examination of the urine 
as a preliminary to every operative procedure. Such an examination 
should comprise the specific gravity, quantity of urea, chemical contents 
as albumin, sugar salts, and approximate quantity of solids. Microscopic 
examination should be a routine part of such an investigation. It 
discloses the character of crystals and casts, their number and appearance; 
the quantity and variety of blood corpuscles and desquamated epithelium; 
the existence of pus corpuscles, amount of mucus, and presence of dis- 
integrating tissue and micro-organisms. Investigation prior to surgical 
measures should include the performance of the respective functions of 
the heart and lungs and a study of the blood. The necessity for operation 
will be determined by knowledge of the number of leukocytes, its wisdom, 
by the number and variety of erythrocytes and the amount of hemoglobin. 
A low percentage of hemoglobin does not preclude operation. I have 
performed hysterectomy on a patient who recovered in whom hemoglobin 
was but 16 per cent. But, a low percentage, associated with a subnormal 
number of erythrocytes, presents an unfavorable condition for prompt 
healing of wounds and renders the individual less resistant to infection. 
Frequently judicious general treatment may render a subsequent oper- 
ative measure successful or may so improve the restorative processes as 
to render it unnecessary. 

The alimentary canal as the sluice-way of the system should receive 
fi.rst consideration, not only as to its evacuation but as to the material 
placed within it. Inflammatory conditions are cut short by abstinence 
and depletion; chronic disorders benefited by increased nutrition; and 
the growth of some neoplasms are arrested by deprivation of food contain- 
ing their principal constituents. The intestinal tract should be swept 
out occasionally by a brisk purgative and efforts made to keep it in a 
good condition by careful adjustment of the diet. Twice a week the 
patient may be given calomel (gr. ss) to be followed the next morning by 
a Seidlitz powder, Rochelle or Epsom salts, or phosphate of soda (3ii)- 



136 GYNECOLOGY. 

Frequently patients are advised to take compound licorice powder at 
night, or a wineglassful of some laxative water in the morning with tem- 
porary beneficial effect, but all such measures sooner or later enslave 
the victim, and the aim should be to free the patient so far as possible from 
the habitual employment of drugs. In sluggish liver, frequent applica- 
tion of hot water is of value which may be enhanced by the addition of 
three ounces of nitro-hydrochloric acid to the gallon of hot water. Am- 
monium chlorid or potassium iodid internally and largely diluted are fre- 
quently beneficial. Efficient elimination by the kidneys should be 
promoted by inhibition of large quantities of water and the use of diuretics; 
where inefficient, want of action should be compensated by increased activity 
of the bowels and skin. The frequent existence of anemia demands the 
administration of reconstructives as quinin, strychnin, arsenic, mercury, 
the bitter tonics and, after proper preparation, iron. 

The profound effect of pelvic diseases on the nervous system renders 
the employment of the antispasmodics acceptable. Valerianate of zinc, 
asafetida and the bromides will afford temporary relief. Nervous and 
anemic patients will be benefited by the cold pack followed by massage. 
The state of the stomach, the heart's action, the character of the respira- 
tion and the general nutrition should always receive consideration. 

95. Specific Remedies. It is difficult to suppose that remedies 
will have a distinctly selective influence on the uterus only. Those which 
have been so regarded are ergot, cotton root, corn fungus, hamamelis, 
hydrastis canadensis, cotarnin hydrochlorat, cannabis indica and vibur- 
num prunifolium. 

Ergot and the remedies exerting similar action are generally given 
in hemorrhage. Its beneficial action is obtained in two ways: i. by 
stimulating the nonstriated muscle fiber of the blood-vessels and in- 
creasing the rapidity of the circulation; and 2. by direct action on the 
uterine muscle, compressing the blood-vessels and promoting the ex- 
trusion of a neoplasm from the walls as a foreign body. Ergot in com- 
bination is generally more satisfactory than when used alone : 

I^. Ext. ergot o j 

Ext. hamamelis, 

Tr. cinnamoni aa f 5 ss M. 

Sig. — f 5j every two or three hours. 

Painful contractions can be ameliorated by combining with each dose 
of the above one to two drops of fluid extract of cannabis indica. 

I^. Ergotin gr- ij 

Cotarnin hydrochlorat gr. j 

Atropin gr. 1/600 

M. ft. capsule No. i. 
Capsule No. XXX. 
Sig. — One capsule four times daily. 

It must be borne in mind that all these remedies acting on the muscu- 
lar coat of the vessels increase arterial tension, and consequently will 
increase rather than diminish bleeding. It would seem more sensible 



THERAPEUTICS. I37 

to place the patient in bed, tampon the cervix or vagina and administer 
nitrites to diminish blood pressure, thus allowing the vessels to become 
occluded. 

Hamamelis and hydrastis undoubtedly owe their action to the large 
amount of tannic acid they contain. Hydrastin or hydrastinin, in doses 
of from 1/8 to 1/4 of a grain, is more effectual in controlling hemorrhage 
than the fluid extracts. 

Viburnum prunifolium has been greatly vaunted as a remedy for the 
relief of dysmenorrhea or the arrest of threatened abortion, but I have 
never been able to obtain any perceptible value from its use. 

The extract of thyroid gland seems to exercise a specific influence 
upon the uterine mucous surface. In women who are very obese and 
have associated with the condition amenorrhea, or very scanty flow and 
sterility, the administration of the thyroid extract, in addition to the re- 
duction of flesh, increases the flow, and frequently appears to overcome 
the sterility. The late Dr. E. H. Coover, of Harrisburg, found thyroid 
extract very effective in allaying the pain of advanced carcinoma of the 
uterus. He also thought that it had an influence in delaying the progress 
of the disease. This opinion seems in harmony with the observations 
of Beatson and others in carcinoma of the mammary gland. 

Thyroid extract is frequently of value in producing an improvement 
in the conditions which occasion uterine hemorrhage, whether these be 
from interstitial endometritis, submucous fibroma, or carcinoma. 
Marked changes in the nutrition and the reduction in the size of myomata 
have been claimed for the use of this drug, but experience does not seem 
to justify them. 

Adrenalin, or extract of the suprarenal gland and tablets of ovarian 
extract, or, better still, lutein tablets made from the corpus luteum, are 
efficient through their action upon the involuntary muscular fibre, ex- 
erting a decided influence upon the uterine circulation. They are, con- 
sequendy, valuable additions to our armamentarium for the control of 
hemorrhage. 

Apiol and the manganese salts cause a hyperemia of the uterine 
mucous membrane, as indicated by increased normal menstrual flow and 
its return in amenorrhea. 

96. Rest and Exercise. It is very difficult to fix definite rules to 
guide a patient as to the amount of either rest or exercise she should take. 
What one person may regard as a pastime another will consider violent 
exercise. Women with inflammatory or engorged uteri are benefited 
by certain hours of rest each day. The recumbent position permits the 
blood-vessels to secure relief. Not infrequently relief is enhanced by 
elevating the foot of the bed or by resting the pelvis upon a firm pillow. 
In predisposition to hemorrhage from fibroid growths, the patient should 
be kept in bed for a few days prior to and during the menstrual period. 
Rest is obligatory in all acute inflammatory troubles. Some patients 
will, however, have to be stimulated to take exercise; they are disposed 
to go to bed on the slightest provocation, and remain so long that their 
muscles become flabby and the vessels grow feeble; the patient becomes 



138 GYNECOLOGY. 

bedridden, and every effort of exertion is attended with real or imaginary 
pain. Such patients may require resort to massage and electricity to 
enable them to resume their ordinary duties. 

Judicious use of the bicycle, encouragement to play golf, automobile 
and carriage riding and systematic exercise will be found most valuable 
auxiliaries in nervous patients who are dominated by imaginary aches 
and pains. The increased oxygenation and elimination without doubt 
free the patient from the cause of her distress. 

97. Baths. The external employment of water, whether as partial or 
complete baths forms a valuable adjunct in the treatment of pelvic disease. 
Heat and cold are applied readily thus to a large surface and, through the 
enhanced activity of the circulation, are transmitted to the deeper struc- 
tures. The heat of the body or of an inflamed part thus can be rapidly 
abstracted. Blood pressure may be increased by cold and reduced by 
hot bathing. The former is stimulating and tonic and the latter depress- 
ing and eliminative. The cold bath (55° to 75° F.) is preferably taken 
in the morning. The patient remains in it from a few seconds to a minute. 
It is followed by a brisk rub with a coarse towel, and active exercise, 
by which the skin surface experiences a warm glow and the individual 
has a sensation of exhilaration. Weak and anemic patients do not re- 
act, hence are unsuitable subjects. 

Tepid baths (75° to 95° F.) can be employed in the less resisting and 
is slightly tonic when not prolonged beyond two or three minutes. If 
continued for a longer period they become depressing. The warm bath 
(95° to 105° F.) is sedative and should be taken at bedtime, and may be 
continued for five to ten minutes. A longer period produces relaxation. 
The hot bath (105° to 120° F.), also preferable at bedtime, may continue 
fifteen minutes. The skin becomes very red. If the bath is prolonged, 
the patient may become very much relaxed and depressed. The bath 
may be sufficient to envelop only a portion of the body. The uncovered 
portion of the body is bathed with friction, preferably by an attendant. 
It is very efficacious in reducing temperature. 

98. The Sheet Bath and the Wet Pack. Nervous and anemic 
patients are greatly benefited by being placed in a cold wet pack and 
covered with blankets. The heat is soon engendered and after the 
patient has been kept in it for an hour or more the pack should be re- 
moved, the surface dried with friction, and active massage employed. 
The patient becomes quiet, composed, and inclined to sleep. The 
patient enveloped in the wet sheet may be subjected to friction through 
it. The procedure deepens the respiration and consequently promotes 
oxygenation. 

The wet pack, according to Baruch, is applied by covering the mattress, 
or, better, a cot, with a rubber blanket and over this a woolen one. A 
large coarse linen sheet is wrung out of water at a temperature of 60° 
to 70° F., spread on the blanket, and so placed that it will extend two feet 
or more beyond the patient's feet. The patient, wearing a wet turban, 
now lies on the cot with her arms extended above her head, covering 
the junction of the middle and right third of the sheet. The latter is 



THERAPEUTICS. I39 

drawn across the body from right to left and tucked along the left side of 
the body. The arms are now placed at the sides of the body and the left 
side of the sheet is carried over them and tucked along the entire right 
side, the blanket in reverse order. Care is exercised to exclude air thor- 
oughly with the blanket. If the patient is chilly, other blankets may be 
applied. This method continued for a length of time is an efficient 
method of eliminating toxins. The wet pack is of value in nervous 
and hysterical cases when followed by massage. The nervous patient 
is greatly calmed by the procedure and may secure refreshing sleep while 
in the pack. It is of especial value in chronic cases characterized by 
defective tissue metamorphosis. When desired, the pack may be a 
partial one limited to the portion of the body on which it is desired to 
exert an especial influence. 

99. The Nauheim bath has long been noted for its influence in 
heart lesions, and has the advantage over fresh-water baths that the chem- 
ical of the salts renders unnecessary the friction employed in the former, 
when less than the temperature of the body, and the processes of matabo- 
lism engendered are more prolongled. The baths are given at a tempera- 
ture varying from 95° to 80° F. and may vary in duration from eight to 
twenty minutes. The action of the carbonic acid is especially beneficent. 
According to Bandler, who has employed it largely in hospital and private 
practice, its results include: slowing of the pulse rate, increased secretion 
of urine, increased oxidation, increased metabolism and breaking down 
of old tissues; regulation of the circulation and even distribution of the 
blood through the various structures of the body; increased demand for 
nutrition; building up of healthy tissue; resorption of exudates; relief of 
congestion, and stimulation of the nervous system and trophic centers. 

It will be understood readily that baths capable of producing such 
marked changes should be given under the observation of a physician. 
As care must be exercised not to overtax the functional energies of the 
body, each bath should be followed by exhilaration. Bandler advises 
them in cases of insufficient development associated with amenorrhea 
and dysmenorrhea; in uterine catarrh indicated by a lack of tonicity 
of muscular and vascular structures; in inflammatory metritis and sub- 
involution prior to marked interstitial hypertrophy; in many cases of 
sterility from latent subacute salpingitis with or without cob-web 
closure of the abdominal end of the tube; in cellulitis and inflammatory 
infiltrations of the pelvic connective tissue prior to sclerosis; in local pelvic 
subinvolution and general subinvolution associated with gastro-enter- 
optosis, and movable kidney; either before or after operation for the re- 
movable of exudation; for the promotion of involution post-partum; 
in cases of obesity accompanied by diminution of the regular menstrual 
flow; in neurasthenic states at the climacteric which are not complicated 
with hemorrhages; and, finally, in rheumatic or gouty conditions. 

The baths may be improvised by adding to thirty gallons of water 
three to five pounds of sea salt, two to four ounces of calcium chloride 
and a half box of Triton salts, the water at a temperature of 95° F. and 
the duration of the bath eight minutes. Following the bath, the body is 



I40 GYNECOLOGY. 

dried with warm towels, the patient given a cup of hot milk or weak 
tea and kept.in bed for an hour. The baths should be given in the morning 
at least two hours after a meal and with each set of three there should be an 
increase of the salts, until with the last, the bath should contain from eight 
to ten ounces of calcium chloride and one box and a half of Triton salts, 
at a temperature of 85° to 80° F. and should be continued eighteen to 
twenty minutes. 

100. The hot air bath has long been recognized as a valuable 
means of promoting elimination. The patient can remain in a room 
raised to a temperature of 130° to 160° F.; sit in a cabinet over an alcohol 
lamp; or have the frame placed over her as she is recumbent, and direct 
the heat from a lamp at the side of the bed. Where a cabinet is not at 
hand, the bath can be improvised by covering the patient with blankets — 
preferably with a rubber blanket or mackintosh externally — and conveying 
heat from an ordinary lamp by means of an elbow of stove pipe. 

1 01. The Electric Light Bath. Where the room of the patient 
is provided with an electric current, the electric cabinet presents a ready 
method of applying heat. It can be in the form of a cabinet in which the 
patient sits, or a hood supplied with a dozen or more lights which can be 
placed over the body of the patient as she lies in bed. The extremities 
are covered with blankets. The hot-air bath, however applied, causes 
perspiration, increases the activity of the skin, and thus favors elimination. 
It proves efhcacious where there is marked vascular tension from arterio- 
sclerosis and especially in defective renal action. 

102. Sea bathing has the great advantage that it can be made a 
diversion and the patient has the stimulus of an exhilarating atmosphere. 
The shock of the cold, the exercise obtained from swimming, struggling 

with and being buffeted by the waves are valuable 
factors. Unfortunately the patient is tempted to re- 
main too long, when the exhaustion and failure to 
react overpower the beneficial results. Properly em- 
ployed, it is efficacious in hastening convalescence 
after operation, in hastening the absorption of exu- 
dates and promoting nutrition. Care should be 
exercised as to the temperature of both air and water, 
better results being obtained in clear weather. The 
patient should be advised to plunge in and get under 
Fig. III.— Sitz Tub the water at once; at the first bath to remain in but 
five minutes and to come out as soon as there is any 
evidence of want of reaction. She should change her apparel immedi- 
ately on coming from the bath and not parade the beach in wet clothing. 
Prolonged bathing, severe chilling of the surface and great fatigue but 
serve to aggravate existing conditions. 

103. The Sitz Bath. The partial bath in the Sitz tub affords an 
opportunity of directing the energies of the bath to the structures most 
affected. It is capable of affording great relief in inflammatory and 
congested conditions of the pelvis. This bath carbonated is of especial 
value. The bath should be followed by rest. It would be contra- 




THERAPEUTICS. 



141 



indicated where there was a tendency to hemorrhage or in possible 
pregnancy. 

104. General massage affords an effective means of promoting 
nutrition and of improving the condition of patients suffering from chronic 
pelvic troubles. It increases the number and the activity of the red 
blood-corpuscles, carries oxygen to the remote tissues and organs, facili- 
tates oxygenation and combustion, and favors absorption. Best of all, 
it improves the nerve tone. Many patients are incapacitated by illness, 
by aggravated pains, or by disinclination to take exercise. Judiciously 




Fig. ii2. — Position of the Fingers in Pelvic ]\Iassage. 

regulated massage accomplishes the constitutional changes ordinarily 
effected by exercise, free from its possible deleterious influences. 
Slowly the individual is rehabilitated, and as she gradually and insen- 
sibly resumes her self-control, she is emancipated from the preexisting 
unfortunate nerve phenomena. 

105. Pelvic Massage. The beneficial results of massage in local 
inflammations of joints and superficial portions of the body justified the 
hope that it might be practised with advantage in the conditions of acute 



142 GYNECOLOGY. 

and chronic exudations within the pelvis. It has been systematized 
into a recognized procedure, known as pelvic massage, largely through the 
study and experiments of Thure-Brandt, a Swedish masseur. 

It is practised by having the patient lie upon her back upon a couch 
or table, with her buttocks close to its edge; the limbs are flexed upon the 
body. One or two fingers of the left hand are introduced into the vagina, 
with which the uterus is gently pushed forward against the anterior 
abdominal wall. The fingers of the right hand are placed upon the 
abdomen, and are moved in a circulatory or rotatory manner over the 
surface, or, rather, moving the surface with them in this manner. (Fig. 
112.) The greatest gentleness must be exercised in the beginning, 
increasing the pressure as the patient becomes reassured or as the pain 
is lessened. As we progress, the fingers may be made to dip down,, 
to push off and separate adherent organs, and to follow lines of cleavage 
indicating inflammatory adhesions. The seances vary in length from 
five to fifteen minutes, the shorter time being preferable in the earlier 
applications, and they should be repeated from three times weekly to 
once daily. The exercise of this procedure will be found to produce a 
rapid alteration in inflammatory accumulations, setting free the uterus 
and its adjacent organs. The procedure will be indicated in all subacute 
and chronic inflammations of the pelvic organs unassociated with pus- 
formation; in displacements, when fixed by inflammatory adhesions; 
in subinvolution and hypertrophy of the uterus from chronic interstitial 
inflammation; and in relaxation of the pelvic floor induced by increased 
weight of the pelvic organs. 

It is contraindicated in the presence of pus-formation, whether con- 
tained in the tubes or within the pelvic tissues. 

Massage is rendered difficult by thick abdominal walls, and in nervous, 
hysteric women. In the latter, however, much may be done by gentle 
procedure until the patient's confidence and cooperation are secured. 

1 06. The Douche. The value of the hot douche was emphasized 
by Emmet. It should be given with a gravity syringe while the patient 
is in a recumbent position; the more prolonged, the larger the quantity, 
and the higher the temperature (116 to 120° F.) the more enduring will 
be its effect. The ordinary fountain syringe, a large vessel with a tube 
leading from its lower end, or an ordinary pitcher with a rubber tube 
carried to and held at its bottom by a weight may be used. Instead of 
the ordinary rubber, wooden or metal nozzle, a glass end piece is prefer- 
able as it can be cleansed more easily. When desired, the water may 
be medicated with such astringents as alum, sulphate of zinc, acetate 
of lead, hydrastis, or hamamelis; or, with antiseptics, as boric acid, car- 
bolic acid (2 to 5 per cent.), formalin in normal solution (1-1500), 
or permanganate of potash (i to 2 per cent.). The difficulty of pro- 
tecting the clothing from stain renders the use of the last agent less 
frequent. Creolin (i to 4 per cent.) and acid sublimate (1-5000 to 
1-2000) are valuable. The antiseptic injections are of especial value 
in vaginal discharge, more particularly when of a specific character. ^ J 

The advent of menstruation is considered a contraindication to 



THERAPEUTICS. I43 

irrigation, but the douche may be resumed before it ceases, particularly 
when the odor is offensive or the parts are irritated, using salt solution at 
a temperature of ioo° F. Frequently the douche of cold salt water will 
be more effective than the hot, but its employment will depend on the 
reaction of the patient. It is more preferable in plethoric than in anemic 
patients. If the vaginal discharge is particularly offensive, as in malig- 
nant disease, a douche of thymol solution, i or 2 per cent., is a more 
excellent deodorizer. 

Astringent douches are used in excessive vaginal secretion, but should 
not be used when the patient is wearing a pessary, as the salts are de- 
posited upon the instrument, roughen its surface, and thus increase the 
irritation. 

Rectal douches may be employed to cleanse the bowel and for the 
relief of inflammation of the rectal mucous membrane or for their effect 
upon the neighboring pelvic organs. The close proximity to the uterus 
and broad ligaments, and the ability to retain the fluid longer in contact, 
make the use of the rectal enemas of hot water of especial value. Medi- 
cated enemas are used to unload fecal accumulations for the relief of 
tympanites, and to medicate local inflammations. 

Vesical douches, medicated or of plain salt solution, are used for the 
relief of inflammatory disease of the bladder and urethra. 

107. External Applications. Hot applications in the form of 
poultices have been the popular form of treatment for acute inflammatory 
conditions, but a far more efficient means of allaying pain and of limiting 
the area of inflammation will be found in the ice-bag. Its persistent 
application will secure resolution in what would otherwise prove a serious 
disorder. Often the cold may be combined with soothing measures 
by applying a compress wet with a solution of lead water and laudanum 
and over this an ice-bag. The ice-bag over the sacrum gives prompt 
relief in dysmenorrhea of the congestive form. 

108. Counterirritants are of especial value in chronic forms of 
disease. The skin of the lower abdomen can be painted with tincture 
of iodin continued so long as the skin will bear repetition. The irritation 
can be increased by the addition of croton oil, as in the following pre- 
scription : 

I^. 01. tiglii, £5] 

Tr. iodi, f 3ij 

Athens, f 3 V. M. 

Sig. — Apply with brush externally. 

A crop of pustules are produced which should be allowed to dry be- 
fore a repetition of the application. 

The most effective procedure is the application of" a blister over the 
seat of pain or to the inflammatory exudate two or three times a month, 
but this should not be practised when the patients are much depressed or 
very anemic. 

109. Bloodletting, or the general abstraction of blood, is now rarely 
practised. Doubtless there are many cases in which a good bleeding 



144 GYNECOLOGY. 

would cut short a severe illness or abort an inflammatory attack. The 
local abstraction of blood by the use of a scarifier or by puncturing the 
cervix will often prove effective in relieving the pain of engorgement and 
in promoting absorption and resolution of inflammatory conditions. The 
beneficial effect can be enhanced further by the previous or subsequent 
employment of the hyperemic glass. 

no. Local applications, formerly, as the routine treatment were: 
the introduction of solid silver nitrate into the uterine cavity, the use of 
fuming nitric acid, and other powerful caustics. Such treatment cured 
by destroying the glandular tissue of the part. Milder measures are 
practised now. It should be an accepted rule that no intrauterine medi- 
cation be employed unless the uterine canal is freely open to permit 
through drainage. 

Intrauterine applications are made by wrapping a probe or applicator 
with absorbent cotton. After having been saturated with a medicinal 
agent, this is carried into the canal. A few drops of the solution may be 



Fig. 113. — Butt Uterine Scarifier. 

introduced by a long pipet. In the use of either procedure, it is desirable 
that the cervix shall be opened freely and the uterus in good position. 
Even when the cervix is freely open, the irritation of the medication will 
often produce contractions causing violent uterine colic. Frequently 
contraction of the uterus will force the solution into the tubes, and result 
in severe inflammation of the adnexa — even the peritoneum. Such un- 
toward results can be avoided by the employment of a Braun's syringe, 
the external end of the stem being perforated at several points in its 
last inch and a half and slightly roughened so that it can be wrapped with 
cotton. The injection of fluid saturates the cotton and brings the solution 
in contact with the surface without having it free in the cavity. To 
render intrauterine treatment of value, the plug of thick mucus which 
generally fills up the diseased cervix must first be removed, so that the 
remedial agent can enter. The agents generally employed locally may 
be classified as i. antiseptic; 2. astringent; and 3. caustic. 

The antiseptic applications are combinations of carbolic acid, creosote, 
iodin and iodoform. Useful preparations are : 

I^. Acid, carbolic, oss 

Tr. iodi, f oj. M. 

I^. Creasoti, ] 

Glycerin., ) aa f o ss. 

Alcohol, J M. 

I^. Iodin (crystals), q.s. ad sat. 

Acid, carbolic. (95 per cent.), f oj. M. 

I^. 40 per cent, solution argyrol. 



THERAPEUTICS. 



145 



As an astringent, a combination of tannin with iodin, as 

I^. Acid tannic, o j 

Tr. lodi, 

Glycerin aa f o j M. 

The most frequently employed applications are the tincture of iodin 
and Churchill's tincture. Iodoform may be used in the form of crayons, 
as an ointment, or as a powder with an insufflator. The various astrin- 



FiG. 114. — Aluminium Uterine Applicator. 

gents may be applied in powder alone or in combination with boric acid, 
iodoform or acetanilid. 

The most available astringents are alum, borax, sulphate of copper and 
sulphate of zinc, the tincture of the chlorid of iron, fluidextract of hydrastis, 
and fluidextract of hamamelis. The solid substances are best used in 
mild solution. Some of these agents when used without dilution are 
stronsrlv caustic. 




Fig. 115. — Long Glass Pipet. 

Caustics. Crayons of sulphate of zinc (50 per cent.) are very effective 
for caustic purposes, and are used in aggravated forms of endometritis. 
Still more effective is the chlorid of zinc in crayons {2)?) P^^ cent.). 

Liquid caustics are nitric acid, acid nitrate of mercury, sulphuric 
acid, hydrochloric acid, chromic acid, solution of zinc chlorid, solution 
of silver nitrate, tincture of iron chlorid, carbolic acid, and creasote. In 
my judgment the more active caustics are rarely required, and very fre- 




FiG 116. — Insufflator — Straight Stem. 



quently their employment is followed by cicatricial changes more grave 
than the original condition. 

III. Tampons are made of absorbent cotton, lamb's wool or gauze. 
The best tampon is composed of a combination of gauze and cotton or 
lamb's wool. It should have a thread attached by which it can be with- 
drawn. The tampon may consist of simple sterilized material, or may 
be medicated with antiseptics, astringents, styptics, anodynes, or altera- 




146 GYNECOLOGY. 

tives. The principal purpose of the tampon is to sustain the uterus at a 
higher level. This relieves the patient from the dragging pains due to 
want of support of a heavy organ, and the change of position improves 
the circulation. The addition of an antiseptic permits it to be retained 
for a long period without becoming foul. Sublimate, from its tendency 
to irritate the vagina and vulva, cannot be used satisfactorily. Boric 
acid, carbolic acid, and iodoform are effective, but the last are objection- 
able because of their odor. The addition of glycerin is of value. Its 
affinity for the watery portions of the blood produces a profuse discharge, 
which depletes the vessels and favors the absorption of exudates. Boro- 
glycerid, glycerite of tannin, and a 10 to 20 per cent, solution of ichthyol 
are popular applications upon the tampon, but the patient should be 

cautioned, in the use of the two latter, to 
^^n&"% J'"§M^: wear a napkin in order to prevent her 

0riiy clothing from becoming stained. 

The tampon may be used not only 
to support the uterus but to control 
hemorrhage or discharge; to complete 
diagnosis, through the discharge which 
it induces; to assist in maintaining the 
uterus in a normal position, and to pre- 
FiG. 117.— Tampon. pare the way for the use of a pessary. 

112. Pessaries. Thirty years ago 
the displacements of the uterus were regarded as provocative of many 
distressing symptoms, which are now attributed to the complicating 
conditions, and the only means of relief beside the tampon was some 
form of pessary. As the invention of a new form of pessary rendered its 
inventor eligible to the title of gynecologist, they multiplied rapidly. 
They were divided into two classes according as to whether or not they 
were provided with external support. The latter were : 

a. Those constructed so large that they were supported by the structures 
below them, as the ring, disc and ball. They served to support the 
uterus at a higher level and prevented prolapsus regardless of the relation 
of the uterus to the pelvic axis. Such instruments were necessarily 
dependent on sufficient retaining power of the pelvic floor to sustain them. 
They were made of soft and hard rubber, of glass, metal and celluloid. 
The soft rubber soon became permeated with the secretions and produced 
an exceedingly disagreeable odor. When worn for a considerable length 
of time, a ring of contracted tissue formed beneath the instrument, which, 
while insuring its retention, made its removal exceedingly difficult, and, 
in the case of the glass balls, very dangerous. The latter have been 
broken in attempted removal and injuries resulted which lead to vesical 
and rectal fistulae. The late Dr. Levis, when such a pessary broke, 
filled the vagina about it with soft plaster of Paris, and when the latter 
hardened, delivered the mass. My colleas^ue, the late Dr. Warder, 
constructed a pair of fenestrated forceps locking them after the blades 
were introduced separately, with which he accomplished the delivery; 
but, by passing two fingers of one hand into the rectum above the pessary 



THERAPEUTICS. 



147 



and stretching and pushing back the vulva and vagina with the fingers 
of the other, the pessary can be delivered safely. 

b. Instruments shaped to the axis of the pelvis, as the Smith-Hodge, 
Munde, Thomas and Schultze pessaries, are used to maintain the uterus 





Fig. 118. — King Pessary, 



Fig. 119. — Disc Pessary. 



in a proper position. They are principally used for retrodisplacements, 
and are of particular value when the condition is recent and due to the 
weight of a subinvoluted uterus. They act by traction on the posterior 
vaginal fornix, which by pulley-like action over the posterior bar of the 





Fig. 120. — Smith-Hodge Pessar)^ 



Fig. 121. — Munde Pessary 



pessary pulls up the cervix and, as a consequence, the fundus falls for- 
ward. By supporting the heavy uterus at a higher level they are 
capable of affording comfort in anteversion and prolapsus. 

c. Pessaries which combine conformation to the form of the pelvis with 





Fig. 



122. — Hoffman Soft-rubber 
Pessary. 



the size to secure retention, as the Hofi'man, Fowler and Zwank pessaries. 
The Hoffman, and Fowler are made of soft rubber. The Zwank has a 
stem and two wings, and can be separated after insertion, but these 



148 



GYNECOLOGY. 



pessaries afford such great opportunities for the retention of decomposing 
secretion that they are very objectionable. 

d . Instruments designed to prevent prolapse of the anterior vaginal wall , 





Fig. 124. — Gehmng Pessary. 



Fig. 125. — Hewitt Cradle Pessary. 



as the Gehrung, Grailey, Hewitt cradle pessary, and the Thomas antever- 
sion pessaries, require a firm support from the muscular structures of 
the pelvic floor to be serviceable. 

e. Intrauterine stems and drainage tubes have been devised to main- 





FiG. 126. — Thomas Anteflexion Pessary 



Fig. 127. — Stem-pessary, 



tain a canal of the uterus and permit a readier exit for its discharge. 
They have been employed with much success in dysmenorrhea, depend- 
ent on obstruction from marked flexions and contractions of the uterine 
canal. The instrument must be worn for several months, and like all 






Fig. 128. — Wylie Drain. 



FiG. 129. — Chambers Drain. 



foreign bodies is prone to produce endometritis and a profuse discharge. 

The pessaries with external support consist of a cup and stem which 

are secured to a belt held about the body by rubber tubes or bands. They 

are employed when the pelvic floor is lost or the vaginal walls so prolapsed 



THER.\PEUTICS. 



149 



that an instrument will not be retained. The cup is apt to induce ulcer- 
ation of the cervdx and vagina from pressure and the stem continually 
irritates the vulva. The tubes are exceedingly unpleasant and soon 
become foul from the absorption of secretions. 




Fig. 129a. — Introducer for Chamber's Drain. 

In recent years the pessary has been almost entirely discarded for 
the more readily executed and effective surgical procedure. Its employ- 
ment, however, in properly selected cases may render operative pro- 
cedure unnecessary. This applies to women who have a heavy subin- 





FiG. 130. — Schultze Pessar}', 



Fig. 131. — Schultze's Sledge Pessary. 



voluted uterus following a recent abortion or labor, where the mainte- 
nance of the organ promotes involution until the ligaments are able 
to continue the support. The intrauterine stems and drains are often 
capable of affording relief when all other procedures fail. In the em- 





FiG. 132. — Cup Pessary. 



Fig. 133. — IMenge Pessary 



ployment of a pessary, there are certain rules which are indispensable for 
comfort and freedom from bad results; 

I. The uterus must be freely movable, readily replaced, free from 
surrounding inflammatory exudate, its cervix not lacerated and the 
vaginal walls capable of aft'ording support to the instrument. 



150 GYNECOLOGY. 

2. The instrument must fit the canal snugly without producing un- 
due pressure. Occasionally the posterior vaginal fornix will be so con- 
tracted from a long existing retrodisplacement as to require preliminary 
stretching with a tampon before a pessary can be worn. 

3. The patient, after the insertion of a pessary, must be cautioned to 
return to her physician or remove the pessary when it occasions pain, 
and she should not wear it longer than a week after its first insertion 
without investigation to see that it is causing no injury. 

4. The pessary should be removed for cleansing at least every three 
months. I saw one patient who had worn one instrument twenty-six 
years without removal. Two-thirds of the pessary was imbedded in 
hard cicatricial tissue. I cut off the protruding part with bone pliers 
and pulled the remaining part out of its track. 

5. The patient should be enjoined to use daily cleansing douches, 
avoiding the use of mineral astringents as the salts of the natural secre- 
tions and particularly of the mineral astringents will deposit on the 
surface of the pessary, roughen it and cause extensive ulceration and 
granulation. 

6. Only instruments constructed of hard rubber or celluloid should 
be employed and these should be especially adapted to the patient. A 
properly fitting pessary can be worn without the patient's being aware of 
its presence and it in no way interferes with the marital relation. 

113. Electricity in the treatment of pelvic disorders has a value 
which cannot be denied. Unfortunately, it requires an expert to secure 
the best results, and it is difficult to combine in one person the reliable 
diagnostician with the experienced electrician. 

Electricity was employed early in an empiric way in gynecology, 
but its use received a marked impetus when Apostoli formulated plans 
for more accurate dosage and systematic practice. In addition to its 
direct effects, electricity appeals to the imagination of the patient and she 
becomes impressed with its possibilities. 

The current may be generated by friction or through chemical action, 
and requires extensive apparatus for its application. The general 
installation of electricity for power and lighting permits the use of the 
street current for the work of the physician. The value of the agent 
depends upon the manner of application and the character of the current. 

114. The static current generated by friction (often called Frank- 
linism) exercises a beneficial influence as a nerve stimulant and counter- 
irritant. It is especially advocated in the treatment of hysteria and 
neurasthenia. The greatest benefit is obtained where the local pelvic 
lesions are slight and pain is the dominant symptom. 

115. The induced, or farradic, current may be used internally, 
externally, or both combined. It has a slight chemical reaction and is 
used as a stimulant. The secondary current is effective in the relief of 
pain in the abdomen and pelvis of neurotic women, and is best applied 
by the bi-polar uterine electrode. The bi-polar uterine electrode with 
this current has been of late advocated in the treatment of uterine fibroids, 
and exerts its beneficial action through promotion of the muscular action 



THERAPEUTICS. 151 

of the uterine walls and consequently more rapid expulsion of the growth 
as a foreign body. 

116. The sinusoidal current envelops the patient who lies on an 
insulated couch in an electrical atmosphere. It is secured by passing 
a current of 450 milliamperes, or over, through a large coil of wire beneath 
the couch, and varying the effect by the number of interruptions to the 
second. This procedure is said to modify nutrition by the increased 
imbibition of oxygen and the greater elimination of carbonic acid induced. 
It exerts a marked analgesic effect which frequently causes the disappear- 
ance of painful symptoms. While of benefit in dysmenorrhea, its most 
marked beneficial results are to be seen in the resorption and disappear- 
ance of pelvic exudates in chronic pelvic inflammation. 

117. The continuous or galvanic current, has been used with a 
marked impetus through the teaching of Apostoli, who demonstrated 
the methods by which the dosage could be determined and a greater 
voltage be employed safely. The influence exerted depends on the 
proximity of the structures to be influenced to the respective poles. Thus, 
the positive pole acts as a sedative to the sensory nerves and as a vasocon- 
strictor of the vessels in its immediate vicinity. In the higher powers 
it acts as a cautery. 

The negative pole, on the contrary, stimulates the collection of the 
alkaline salts in its vicinity and exerts a greater chemical action on the 
tissues. Its most beneficial effects in gynecology are seen in the relief 
of pain in dysmenorrhea and in the treatment of chronic endometritis 
and pelvic exudates. While its long continued hemolytic action lessens 
the hemorrhage in submucous and interstitial fibroid growths, this dis- 
tressing symptom can be speedily and successfully relieved in other ways. 

118. Rontgen discovered the peculiar influence induced by electric 
excitement on light when transmitted through tubes of high vacuum. 
The rays so induced, he named the X-rays. They have proven both 
diagnostic and therapeutic. Their employment has proven of especial 
value in the treatment of the eruptive diseases of the external genitalia. 
Accidentally it has been discovered that the abnormal hemorrhages and 
discharges can be controlled effectually through their use. The use of* 
the X-rays has not only been found to lessen and even arrest the hemor- 
rhage, but also leads to a reduction in the sizes of the growths. This 
action is doubtless due to the inhibitive influence of the rays on the action 
of the ovarian secretion. Their continued use results in the establish- 
ment of sterility and the climacteric, consequently the action upon the 
fibroid growth is similar to that which takes place subsequent to the 
menopause. When the growths are of considerable size, the ovaries 
may be so covered and protected by them that the rays do not penetrate 
with sufficient force to effect the necessary alteration to arrest hemor- 
rhage and bring about retrogression of the tumor. In superficial forms 
of malignant disease, the rays have a restrictive influence in the progress 
of the disease and in some cases may result in the entire disappearance of 
the local manifestation. This fact, however, should not lead to the use 
of the X-rays where the local manifestations are so situated that a hope- 



152 



GYNECOLOGY. 



ful operation can be performed. In the manifestation of malignant 
disease, in the deeper structures, around the uterus or in the area immedi- 
ately surrounding the field in which hysterectomy has been done, I have 
been unable to see any beneficial results from the use of the Rontgen 




Fig. 134. — Portable Galvanic Battery with Balvanometer. 

rays. The discomfort in attempting to make the rays effective in these 
deeply seated structures is not compensated by the beneficial results 
obtained. 

119. Contraindictions. According to ApostoH, the galvanic cur- 
rent is contraindicated in the following conditions: (i) hysteria; (2) 



Fig. 135. — Intra-uterine Electrode with Movable Insulating Cover. 

intestinal catarrh; (3) pregnancy; (4) malignant degeneration of a tumor; 
(5) fibrocystic tumors; (6) suppurative inflammation of the adnexa. 
To these, Schaeffer would add any acute or subacute inflammation of the 
pelvic viscera, a very hard or fufly matured tumor, an excessively large 



THERAPEUTICS. 



153 



growth, a submucous growth which is pedunculated, enfeebled heart action, 
or acute nephritis. 

I20'. The Finsen light consists of the ultra-violet rays, which are 
invisible to our vision and are capable of refraction and concentration. 
They exist largely in sunlight, but may be artificially produced from the 
arc light. Glass is a nonconductor to these rays, therefore it is necessary 




Fig. — 136. Vaginal Electrodes of Different Sizes. 

to construct a plate or disc of quartz, or, still better, of transparent rock- 
salt. The Finsen light differs from the Rontgen rays in being very 
destructive to bacterial life, while the latter, if it has any effect, rather 
facilitates bacterial growth. The application of the Finsen light must, 
under present conditions, have a limited application in gynecology, 




Fig. — 137. Faradic Battery. 

because it causes an anemia of the tissues upon which it is purposed to 
exert its influence. 

121. Electrocautery and Light. The employment of electricity 
as a means of producing heat for cautery has won a well-recognized 
place through the work of Byrne with the galvanocautery, and later its in- 
genious application by Skene and Downes to electrothermic hemostasis. 



154 GYNECOLOGY. 

The power can be secured by batteries of large size, by storage cells, 
or, better, from the street main through a transformer. Dr. Downes has 
modified and improved the instruments devised by Skene. He, applies 
to the broad ligaments a special form of angiotribe which, when raised 
to a dull red heat, divides and cooks the tissues, thus rendering ligatures 
unnecessary. 

The great advantage of this procedure is in hysterectomy for cancer 
of the uterus, as it enables the removal of a large amount of possibly 




Fig. 138. — Bipolar Uterine Electrode. 
+ Positive pole. — Negative pole. 




infected tissue. The malignant cells which have been carried into the 
parametrium are supposedly less resistant to the effects of heat than 
healthy tissue. Therefore it seems reasonable to infer that some of these 
are destroyed by the electrothermic measures which would otherwise 
survive to cause relapse if other methods of operating had been employed. 
The same class of batteries employed for cautery purposes also may 
be used for electric light which is especially useful in inspecting the urethra, 
bladder, ureters and rectum. The electric light in a cystoscope can be 
introduced through the urethra and the entire cavity of the bladder ex- 
posed, the orifices of the ureters recognized, and any changes in the struc- 
ture of the bladder readily observed. The instrument may be employed 




Fig. 139. — Vaginal Electrode — Bipolar. 

to irrigate the bladder by closing its end; the bladder can be distended with 
air or gas, thus determining the capacity of the organ. Loss of structure, 
thickening, growths, and other changes in its walls are also perceived. 
It also can be employed for local medication and for catheterization of the 
ureters. The electric light can be employed to illuminate the rectum 
through long or short proctoscopes; the vagina by an attachment to a 
speculum; and even to look into the uterus, but as the latter canal has to 
be previously dilated, the instances are rare when its illumination will 
be of practical service. 

122. Radium. The recent investigation of Tuffier and others on 
the action of radium have demonstrated its beneficial influence in car- 
cinoma uteri, myomata and metritis. In cancer, its eft'ect has been to 
render operable cases which previously were regarded as belonging to the 



THERAPEUTICS. 1 55 

inoperable class and as arresting the progress of development when the 
disease had recurred subsequent to hysterectomy. Should subsequent 
investigations confirm the experiences so far secured, it will become 
advisable to employ this agent as a prophylactic against recurrence after 
every radical operation. 

The radium salt of high potency confined in glass tubes or discs covered 
with caoutchouc web or a thin screen of lead foil or aluminum is placed 
in the vagina and protected by a gauze or cotton tampon. The applica- 
tion is permitted to remain twelve to sixteen hours — occasionally twenty- 
four hours. A daily application is made for a series of five or six days, 
after which ten days' interval is allowed to transpire before the next series. 
In fibroids and metritis, a stem for insertion into the uterus is also 
employed. The treatment, it is claimed, results quickly in an arrest of 
hemorrhage, cessation of discharge and amelioration of all unpleasant 
phenomena. 

123. Infection. The discussion of the action of the micro-organisms 
(see diagnosis) has prepared the student to appreciate the importance 
of combating infection in its various manifestations. Frequently deaths 
following operations are attributed to heart failure, shock, pyelonephro- 
sis, and pneumonia when, without question, these lesions have been the 
result of infection. Infection reaches a wound more frequently from 
unclean hands or instruments than through the atmosphere. 

Terms: The study of the phenomena of infection has originated 
the terms sepsis, antisepsis, and asepsis. Sepsis indicates the existence 
or sequela of infection; antisepsis, the employment of agents which are 
either destructive to bacteria or restrain their baneful influence; asepsis 
comprises the exercise of measures to exclude from the field of operation 
all pathogenic germs and their products. The latter is the ideal proce- 
dure, but when we come to deal with agents so intangible that a micro- 
scope is required to reveal their presence, and so occupying the atmos- 
phere as to render it absolutely impossible to preserve aseptic or sterile 
everything that may come into contact with the affected tissues, a com- 
bination of the two methods seems a wiser plan of procedure. 

Sterilization means the entire destruction or removal of germs. Com- 
plete sterilization of everything is an ideal asepsis. 

124. Methods of Sterilization. The most effective method of 
sterilization is to use the flame, but its action is necessarily limited because 
of its destructive influence on the temper of instruments. It is employed 
to destroy worthless and dangerous objects such as soiled dressings. 
Either dry or moist heat may be employed. The vegetative bacteria 
are destroyed by comparatively low temperatures, from io6°F. to 150° F. 
The spore-bearing bacilli require a higher temperature and stronger 
chemical solutions. 

Sterilization by dry heat is infrequently employed, for the reason that 
a temperature of 284° F. for three hours is required to insure the destruc- 
tion of the spore- producing micro-o:-ganisms (Robb). It is rendered un- 
available, not only by the time required, but also because it is injurious 
to instruments and destructive to ligatures and dressings. 



iS6 



GYNECOLOGY. 



An effective and easy method of sterilization is by the use of steam, 
which requires an apparatus from which the air can be expelled and the 
temperature maintained evenly at 212° F. A convenient and cheap 
apparatus for this purpose is an Arnold copper sterilizer. (Pig- 140.) 
The most effective sterilization is accomplished in a sterilizer which 
employs superheated steam under pressure. Steam at a temperature of 
220° to 230° F. at a pressure of 15° insures the sterilization of large pack- 
ages, but to prevent reinfection the sterilized packages should be thor- 
oughly dry before removal from the sterilizer. The sterilizing apparatus 

is usually so constructed that 
steam can be turned out of the 
central chamber into the sur- 
rounding jacket and thus insure 
the drying of the contents of the 
chamber. Ligatures and sutures 
may also be sterilized in the same 
way, but more effectively by boil- 
ing. Silk will not stand long or 
repeated boiling without becom- 
ing friable. The towels, sheets, 
and operating gowns should be 
subjected to what is called the 
fractional method. This con- 
sists in placing the material in 
the sterilizer for one hour the 
first, and one-half hour each suc- 
ceeding day for two days. When 
dry and protected properly, they 
will remain aseptic for an in- 
definite time. 

125. The instriiments for 
examination and operation should be capable of being cleaned thor- 
oughly. They should be cleansed after every operation and boiled 
before the next. They should be placed in trays dry, or upon a sterile 
table. It was formerly the custom to place instruments in a 5 per 
cent, solution of carbolic acid. If the instruments are cleansed 
properly, the use of this agent is unnecessary, and in many operative 
procedures, particularly those upon the peritoneal cavity, it is objec- 
tionable, as it causes irritation of the delicate structure of the 
peritoneum. The instruments should be sterilized before beginning 
an operation. Davidson says five minutes' boiling in water destroys all 
germs, but if the instruments have been used in pus or about gangrenous 
cases it is important that we should exercise still further precautions to 
render them absolutely sterile. They may be boiled for ten minutes 
in a 5 per cent, solution of carbolic acid. The water should be boiling 
before the instruments are placed within it or they will rust. Rusting 
can be prevented by using a i per cent, solution of carbonate of soda. 
This method of procedure affords a ready means of sterilizing an instru- 




FiG. 140. — Arnold Steam Sterilizer. 



THERAPEUTICS. 



157 



ment which has been dropped during an operation. It has the advantage 
that any vessel can be used. The instrument trays — preferably of glass 
or porcelain, as being most readily disinfected — should be sterilized by 
heat, or, after careful washing with soap and hot water, should be filled 
to the brim with 1 1500 solution of bichlorid. Trays should be emptied 
and washed out w^ith plain sterilized water before the instruments are 
placed in them. 





Fig. 141. — Steam-pressure 
Sterilizer. 



Fig. 142. — Sterilizer for Boiling Instruments. 




126. Sponges. The ordinary sea sponge is rarely used. Dry gauze 
pads are used almost exclusively for walling off the intestines and mopping 
the operating field. They are made by taking a yard of gauze and folding 
it so that all raw or selvage edges shall be turned in and the possibility 
of leaving portions of the fibre in the wound or cavity avoided. It is 
well to have several longer folds of gauze for packing or walling off the 
cavity. They are done up in pack- 
ages and must be sterilized by the frac- 
tional method and kept free subsequently 
from any infection. The person who dis- 
penses them at the operation should 
handle them only with sterilized metal 
instruments. 

The greatest care must be exercised 
to make certain that all pieces of gauze 
are accounted for before closing the 
abdominal cavity. It is advisable to 
assign two persons to the sponges. One gives them out, and as she 
does so counts them. The second person accumulates and counts the 
sponges after removal from the wound. The tally of sponges issued 
and received should agree before the wound is closed and the operator 
should satisfy himself by very careful examination that none are retained. 
An aseptic sponge may be retained without delaying the healing of the 






Fig. 143. — Gauze Pads. 



158 GYNECOLOGY. 

wound and become encysted, but later may form an abscess and open 
externally into the vagina, bladder, or rectum. Occasionally a large 
vessel may be eroded and a fatal internal hemorrhage occur. When the 
operator has to depend upon uncertain assistants, it is better to return 
to smaller pieces of gauze, which can be washed and used over and over 
during the operation. 

127. Ligature and Suture Material. Silk, twisted or plaited; 
linen; silver or iron wire; tendon; silkwormgut; catgut; and horsehair 
are some of the materials employed for ligatures and sutures. 

Silk has the advantage that it can be prepared quickly or sterilized by 
boiling. It is still used by many surgeons both as suture and ligature. 
To overcome the objection that the fluids enter its substance and that 
it acts as a seton or drain, it is wrapped on glass slides, boiled for thirty 
minutes, washed in alcohol, dried and then soaked for forty-eight hours 
in a solution of gutta percha in turpentine (1:10), boiled for an hour in 
normal salt solution and stored in a solution of chinisol (i : 500) or an 
alcoholic solution of periodid of mercury (1:800). (Webster.) 

Linen thread should be impregnated with celloidin. It is prepared 
as follows: i. To rid the thread of its grease, it is boiled in a soda solution 
and washed in cold water. 2. It is boiled in sterile water for six minutes 
and placed for six hours in absolute alcohol, when this process is again 
repeated. 3. It is dried in a warm chamber and rolled on glass spools. 
4. The spools thus wrapped are placed for thirty-four hours in a 30 per 
cent, solution of celloidin in equal parts of alcohol and ether, to which i 
per cent, of sterilized castor oil has been added. 5. The sutures are 
rolled on a wooden frame to dry and the excess of celloidin is removed 
with sterilized paper. They are kept in a closed glass jar and are twice 
boiled in a 1 : 1000 solution of corrosive sublimate before using (Webster). 
The possibility of infection of silk or linen when used upon the stump of 
a suppurating tube, or in a pelvic cavity when suppuration is present, 
or the long-continued sinus that results until the ligature itself has 
discharged, has led me to prefer some material for ligation that is more 
certain to be absorbed and will not remain in the tissues so long. I have 
had occasion to open a sinus and remove a large ligature from a patient 
upon whom the operation had been done four years before, while the 
abscess did not form for three and one-half years. Consequently, for 
some time I have used nothing but catgut for ligatures and internal 
sutures. This material, when carefully prepared, is perfectly safe, and 
we have no reason to feel that the patient will experience inconvenience 
after convalescence occurs. Patients in whom no suppuration has oc- 
curred, nor sinus resulted, have subsequently suffered from pressure upon 
the nerve-fibers by an encysted ligature, requiring reoperation a year or 
more later for removal of the ligature in order to secure relief. Catgut 
for ligature is prepared as follows: No. 00, No. o, and No. 2 catgut, as 
obtained from the shops in long pieces, is placed in ether or benzin for 
a number of days, or even weeks, to extract the fat. It is removed from 
this and tightly wrapped upon wooden blocks or glass tumblers, and 
placed for thirty hours in a solution of dichromate of potash : 



THERAPEUTICS. 1 59 

I^. Potassii dichromat i ■ 5 

Acid, carbolic, \ 

^, . ' > aa lo.o 

Glycerin, j 

Aqua, 480 . o 

The dichromate is dissolved in the water, and the carbolic acid and 
glycerin are added. 

Fixing of the gut before its immersion in the solution is very im- 
portant, as it otherwise becomes hopelessly twisted and entangled. 
After removal from the solution the strands should be wrapped upon 
prepared boards about a meter long, and while so wrapped they should 
be dried carefully. From these boards it is cut in meter lengths, and 
the pieces are wrapped tightly upon glass drainage-tubes. Each tube 
contains two pieces of gut. These tubes are placed in a i : looo solution 
of sublimate in water for eight hours. This solution is poured off and 
replaced by a 1:500 solution of sublimate in alcohol (90 per cent.), in 
which the catgut remains for twenty-four hours. From this solution the 
tubes are lifted by sterile forceps into absolute alcohol, to each half pint 
of which one dram of sterile glycerin has been added. The tubes are 
removed from this solution for use. Any catgut unused after an opera- 
tion is not replaced. 

No. 2 gut is employed for ligatures. No. 00 and No. o for sutures. 
Gut so prepared is, in my experience, an unirritating and satisfactory 
material for ligatures and sutures. 

When it is not desired to harden the catgut, or there is no need of its 
remaining in the tissues for a length of time, the solution of dichromate 
of potash may be omitted. Catgut prepared by immersion in solutions 
of iodin, formalin, or the silver salts is claimed by its advocates to resist 
infection within the tissues of the body. 

Dry lodin Catgut. The commercial catgut cut to suitable lengths is 
wrapped in single layers on glass tubes and each end of the piece secured. 
It is immersed eight days in a solution containing one part each of iodin 
and potassium iodid to 100 parts of water. The solution is then poured off, 
the vessel covered with several thicknesses of gauze and dried. The 
catgut is kept in well closed jars or bottles to prevent volatilization of the 
iodin and used dry. (Moschowitz. Annals of Surgery, Vol. xlii, 1905, 
P- 321.) 

Formalin Catgut. Take dry catgut 10 feet long wound around a 
glass drainage tube, submerge in a 3 per cent, formalin solution in which 
it remains from one to four hours; place in running water an equal length 
of time and dry in the open air. It becomes mercerized by the process 
and should be kept dry. (Congdon. American Journal of Obstetrics, 
Vol. li, 1905, p. 47.) 

Silverized Catgut. Commercial catgut wound on glass reels is sub- 
merged in a I per cent, solution of silver lactate (actol) in which it is 
allowed to remain for eight days, during which time the glass jar is wrapped 
in cardboard to keep out the light. The liquid is then poured off. 
The jar covered with four thicknesses of gauze is exposed to the light 
until the strands turn black, when it is washed in water until the latter 



l6o GYNECOLOGY. • ' 

remains clear. The jar is again covered with four thicknesses of gauze 
and kept in a warm place until the catgut is thoroughly dry. When used 
the catgut is placed in 60 per cent, alcohol. (MacClure. Annals of 
Surgery, Vol. xlviii, 1908, p. 769.) 

It is claimed for all of these preparations of catgut that the sutures 
and ligatures have an inhibitory influence on septic processes even when 
placed in pathogenic material. Chromic catgut may be submitted to 
one of these processes subsequently, the better to insure its being 
inocuous. 

Horse hair sutures are used principally to approximate the skin edges, 
but it is less advantageous than the plain catgut which does not have to 
be removed. A number of manufacturers now put up catgut in alcohol 
or chloroform sealed in glass tubes, in which it is kept free from contam- 
ination until desired for use. It is thus prepared plain or chromicized. 
By some it is marked 10-, 20-, or 40-day catgut, but experience has taught 
me not to place reliance on such promises. In the acid secretion of the 
vagina, none of it is certain to last more than ten days or two weeks. 

Silkworm' gut forms an excellent suture, is clean, not readily infected, 
and easily taken care of. It may be boiled ten minutes prior to the 
operation. 

The nurse or attendant in handling the sutures should wear rubber 
gloves. Catgut never should be drawn through the bare hands. The 
tubes containing the sutures and ligatures should be immersed for a few 
minutes in a i: 1000 solution of corrosive sublimate, or, still better, boiled 
for two minutes before they are broken. 

128. Dressings of gauze medicated with various germicidal or inhib- 
itory agents have been advocated, but they present no advantage over 
sterilized gauze. The latter is nonirritating and serves every purpose. 
It should be sterilized by steam, the fractional method being employed. 
The sterilization should continue one hour the first day, the second day 
half an hour, and the third day the same length of time. When dried 
the gauze should be wrapped carefully until it is used. 

129. Personal cleanliness of the operator and assistants should 
be a matter of conscience. A person with nasal catarrh or bad breath 
from decayed teeth or foul stomach is disqualified to be either an operator 
or assistant. This is particularly true in peritoneal operations. Even 
the slightest examination should not be undertaken unless the hands and 
nails are carefully cleansed, in order to insure against the introduction 
of infectious material, and in every operative procedure the hands and 
arms should be scrubbed with soap and hot water, giving thorough at- 
tention to the condition of the nails. The longer the hands are scrubbed 
with soap and water, the less active are the germs that inhabit the surface 
beneath the finger-nails. After thorough washing with soap and hot 
water, the nails should be scraped and the washing again repeated. The 
fingers, especially about the nails, should be scrubbed with a piece of 
sterile gauze wet with a i : 500 solution of bichlorid in 70 per cent, of 
alcohol, and subsequently washed in sterile water. Probably still better 
is a solution suggested by Charles Harrington, of Boston, which consists 



THERAPEUTICS. l6l 

of commercial alcohol (94 per cent.), 640 c.c; hydrochloric acid, 60 c.c; 
water, 300 c.c; corrosive sublimate, 0.8 gram, in which the hands and 
arms should be bathed for thirty seconds to a minute after having been 
washed thoroughly with sterile soap and hot water. I have used this 
solution for several years with gratifying results. Nurses and assistants 
who are to take part in the operation and handle sponges or dressings 
should be required to exercise the same precautions rigidly, and should 
be taught the importance of carefully avoiding contact with any nondis- 
infected article. If they should accidentally touch a door, basin, cloth- 
ing, the face, or any nonsterile object, they should again scrupulously 
cleanse their hands before coming in contact with dressings or instru- 
ments. Chemical disinfection of the hands after scrubbing with soap 
and hot water by immersion in a solution of permanganate of potash 
(4: 1000), then in a concentrated solution of oxalic until this stain is re- 
moved, then in lime water and finally in sterile water, has been advocated. 
Another method is to wash them with equal parts of sodium carbonate 
and calcium chlorid to which water is added gradually. The chlorin 
set free is the effective agent. There are but few persons, however, 
whose hands will endure the use of either of these methods of cleansing 
several times daily. 

Before examining a case of cancer, where there is considerable de- 
composing material, it is well to anoint the fingers with turpentine and 
afterwards with vaselin as thus the disagreeable odor is removed more 
readily from the fingers. Rubber gloves, or a common condom drawn 
over two fingers before examining cancer or other infectious cases is 
preferable. The impossibility of securing absolute sterility of the hands 
and the varying susceptibility of different individuals to the influence of 
infectious germs makes the habitual wearing of rubber gloves a prudent 
policy. Certainly surgeons engaged in general surgical practice do wisely 
to wear rubber gloves when operating within the peritoneal cavity. 
Gloves must be worn when the operator has recently examined or operated 
upon patients who were suffering from some infectious disease. 

During the operation, the operator should have conveniently situated 
two vessels, one containing a solution of i : 1000 acid sublimate, and the 
second sterile water, into which he can occasionally dip his hands. In 
operations within the abdomen it is better that the bichlorid should be 
replaced by sterile water. He should wear clean linen and should have 
his clothing entirely covered by a sterilized apron. When there is much 
fluid, as in plastic operations on the vagina, in which continued irrigation 
is practised, the clothing should be covered with some waterproof mate- 
rial beneath the apron. Where conditions will permit, it is better that the 
surgeon should make a complete change of attire, both in the interests 
of his own health and for the safety of his patient. 

130. The room and environment of the patient should receive 
careful consideration. The room should be well lighted, ventilated and 
thoroughly cleaned, free from matting, hangings, and everything that is 
likely to retain dust. In fact, no more furniture should remain in the 
room than is absolutely necessary. The operating room should be one 



1 62 GYNECOLOGY. 

whose walls can be washed thoroughly and cleansed carefully. Its 
furniture should be made of metal and glass. When the operation is to 
be performed in a dwelling, the room should be scrubbed carefully with 
a carbolic-acid solution (50:1000) two days in advance. In a private 
house where the rooms are old, or their condition at all suspicious, they 
should be disinfected with formaldehyd apparatus. It was formerly 
the practice to operate under the carbolic acid spray, but it was found to 
have a prejudicial influence upon the peritoneum. Until quite recently 
some operators still kept a spray in the room for the moisture and to 
secure the beneficial influence of the carbolic acid, but the drug is so 
disagreeable and injurious to many patients that the practice has been 
discontinued. Sterilized water should be at hand in carefully covered 
vessels, and when antiseptic solutions are used, they should be so designated 
that no mistake can be made. 

131. In the preparation of the patient the action of the skin 
shou'd be promoted and cleanliness secured, where the condition of the 
patient will permit, by a full bath. The diet must be regulated accord- 
ing to the character of the operation. In peritoneal and intestinal opera- 
tions, milk and other foods containing much waste should be excluded. 

A thorough evacuation of the bowels should be secured by the admin- 
istration of half an ounce of RocheUe or Epsom salts; two drams of 
compound licorice powder; half a bottle of magnesium citrate or an 
ounce of castor oil, two nights previous to the day set for the operation. 
A large rectal enema of soapsuds should be given the preceding night. 
The patient should be kept in bed for twenty-four hours prior to a serious 
operation. 

Special attention should be given to washing the external genitals, 
the anus and the depression of the umbilicus. Vaginal irrigation with 
1:2000 sublimate solution should accompany each bath and may be 
given without it. The abdomen and genitalia should be shaved the even- 
ing before operation and the abdomen washed with tincture of green 
soap and hot water, the flesh brush being diligently applied. If the 
patient is uncleanly, or the skin is oily, the surface should be washed with 
ether, then with soap and water, and finally with 60 per cent, alcohol. 
This washing should be repeated on the morning of the operation, and 
the abdomen covered with a pad saturated with sublimate solution, re- 
tained by a bandage, to be removed when upon the operating-table. 
In all cases it is desirable that the field of operation should be again 
thoroughly scrubbed after the administration of an anesthetic, with soap 
and hot water, the superfluous soap being removed with alcohol. 

Special preparation for vaginal operation should consist in a careful 
cleansing of the vagina. For this purpose a combination of creolin with 
green soap is very effectual, using creolin, one or two drams, and green 
soap, one or two ounces, to the quart of hot water. The vaginal canal 
should be scrubbed thoroughly with this solution, introducing two fingers 
wrapped with gauze. This procedure will remove all debris which may 
have lodged in the crypts and folds of the vagina. The solution should 
be removed by washing with sterilized water, then with alcohol. Creolin 



THERAPEUTICS. 1 63 

is not SO effective an agent in sterilizing the vagina as the acid sublimate 
solution, but it has the advantage of leaving the vagina soft and flexible, 
which is an important consideration in obstetrics as well as in all operative 
procedures upon the vagina. The bichlorid and carbolic-acid solutions, 
on the other hand, have a constringing effect upon the vagina, which 
renders it less elastic. 

132. Irrigating tubes and cannulas used for the purpose of cleans-- 
ing the vagina should be made of glass (Fig. 144), as they are more 
readily cleansed, less likely to contain infectious material, and are suffici- 
ently cheap to permit them to be thrown away when used in suspicious 
cases. If injections are used by the patient, there* should be no central 
opening of the nozzle, for it may be introduced directly into a patulous 
cervical canal, and fluid thrown with force into the cavity results in severe 
uterine colic. Indeed, fluids have been thrown into the uterus and 
forced by uterine contraction through the tubes, which caused serious, 




Fig. 144. — Irrigating Glass Tube. Open End, 

if not fatal, pelvic inflammation. There is no special advantage in having 
a curved cannula or tube for irrigation. The nozzle used by the physician 
in an operation should have but a single orifice, and that a central one. 
After irrigation has been practised, pressure should be made upon the 
fourchet, to insure the entire escape of fluid. It it sometimes advised 
that the irrigation should follow the examination or operation, but we can- 
not impress too strongly upon the student the fact that the genital canal 
sometimes contains dangerous germs, and that antisepsis must precede 
as well as follow an operation. In cancer or sloughing fibroids in addi- 
tion to the ordinary disinfection we may require the use of deodorizing 
agents. For this purpose may be used a 3 to 5 per cent, solution of 
thymol, or two or three tablespoonfuls of Labarraque's solution to the 
quart of water. 

133' Gauze. After the uterus and vagina are cleansed carefully 
the canal may be packed with iodoform or other antiseptic gauze which 
will remain sweet for a number of days. Iodoform gauze is preferable. 
To prepare it, ten layers of plain gauze are sterilized by boiling, prefer- 
ably in a solution of carbonate of potash, washed, then soaked in a solu- 
tion consisting of iodoform 50, glycerin 100, and ether 700 parts, after 
which the gauze is passed through a wringer and dried in a darkened, 
isolated room at a temperature of 85° F. When dry, it is placed in tin 
boxes. This gauze should always be sterilized before use. This can 
be accomplished best by heating it to the temperature of 250 F., by 
which both germs and their spores are destroyed. It should be remem- 
bered that iodoform is not a germicide. Its value is in its reductive influence 
upon the ptomains and leukomains, by which their deleterious effects 
are arrested. Iodoform is poisonous to some patients in whom it produces 



164 GYNECOLOGY. 

high temperature, irritation of the skin, and a smoky, darkened urine, 
and in others extreme disturbance of the digestive tract. In such idiosyn- 
crasies one of the other forms of antiseptic gauze should be preferred. 
These comprise borated, salicylated, carbolized, formahzed, and acetan- 
ilid gauze. Sublimated gauze can be made by boihng it first in a solution 
of carbonate of potash (20:1000), then an hour in a (1:1000) sublimate 
solution, when it is dried in a sterilizing oven and preserved in closed 
glass jars. Salol and iodol are inferior in their action to iodoform. 
Carbolic acid is unreliable. Aristol, a powder made by the combination 
of thymol and iodin, is probably preferable to iodoform. It has the 
advantage of the absence of disagreeable odor, is very dry, not rapidly 
soluble, and coats over and protects the surface. 

134. Antisepsis of the cervix and uterine cavity is secured by 
intrauterine injections of sublimate solution, carbolic acid, dioxid of 
hydrogen, or, preferably, formalin (i : 1000) . Of the solutions of mercury, 
the acid sublimate is better for the reason that it does not form an album- 
inate of mercury by combination with the serum of the blood, and is less 
likely to be absorbed and to produce a toxic effect. This agent is not as 
dangerous as in obstetrics, unless there has been a large denuded surface. 
In such cases its use should be followed by an injection of sterilized water. 
I prefer a hot i to 2 per cent, solution of sodium chlorid or a 2 per cent, 
solution of the sodium bicarbonate for irrigation of the uterine cavity 
during or following a curetment. It is fully as efficient as the stronger 
germicidal agents, and if a perforation should occur, or fluid pass through 
the tubes, this fluid will prove innocuous in the peritoneal cavity. 

In order that the return flow may not be obstructed in intrauterine 
injections a double catheter should be used. It may be made of hard 
rubber, glass, celluloid or metal; the last named is more likely to be acted 
upon by the mercury salts. If the uterine cavity is well dilated, the double 
tube will not be necessary. After the uterine cavity is carefully cleansed, 
it may be packed with iodoform gauze or a pencil of iodoform may be 
introduced. Von Hacker recommends the following: Iodoform, 5 
drams; gum acacia, glycerin, starch, each 30 grains; mix, make pencils, 
introduce into the cavity of the uterus. When these pencils give rise 
to uterine colic, it may be preferable to dust the cavity with iodoform 
through an insufflator, or, still better, to use aristol by the same means. 

In sloughing fibroids or intrauterine cancer, the uterus should be 
irrigated with an acid sublimate solution (1:2000), followed either by 
sterilized water or a solution of chlorid of sodium (6 : 1000) . The offensive 
odor probably will be controlled more effectually by irrigation with per- 
manganate of potassium (4 per cent.) or a 2 per cent, solution of thymol. 
In operations upon the vagina or cervix continuous irrigation may be 
practised, using for this purpose a solution of carbolic acid (5:1000), 
sublimate (1:2000), formalin (1:1000), or, better, chlorid or sodium 
(6:1000). The irrigation washes away the blood, renders unnecessary 
the use of sponges, and the surfaces are constantly kept bathed with the 
antiseptic fluid. It is the preferable procedure in all operations upon the 
vulva, vagina, and cervix. 



THERAPEUTICS. 1 65 

135. The Use of Tents. In dilating the uterus the sponge, tupelo, 
or laminaria tents, although carefully disinfected, are not without danger. 
Pozzi recommends the latter tent, but he first immerses it in a saturated 
solution of carbolic acid and rectified spirits, or in a solution of iodoform 
and ether with a tenth part alcohol. In my judgment the best method 
of rendering the tent safe is to immerse a laminaria (or series of such tentsj 
in the official tincture of iodin for a few minutes prior to its introduction 
into the uterine cavity. The objection to the use of tents is the difficulty 
in sterilizing the uterine canal prcA'iously. Unless it is thoroughly done, 
as in the performance of any operation, the patient is in dano^er of sub- 
sequent inflammatory attac s. For this reason except when a digital 
exploration of the uterine cavity is required, I prefer to accomplish rapid 
dilatation by bougies in preference to the slower method with the tent. 

136. Abdominal Section. The peritoneum is a membrane exceed- 
ingly susceptible to the influence of all chemic agents, and its delicate 
structure would be injured or destroyed by any agent of sufficient strength 
to have a germicidal influence; consequently, our aim should be rather 
to procure asepsis than antisepsis. Assistants must be personally clean. 
They should take a thorough bath and see no case of contagious disease 
prior to the operation. They should remove their coats and vests, bare 
their arms to above the elbows, thoroughly scrub their hands and arms 
with soap and hot water, and wash in disinfectant solutions. Their 
clothing should be covered with clean sterile linen. They should sub- 
sequently avoid shaking hands or touching any objects not disinfected. 
The greatest immunity to infection will be secured by the operator and 
his assistants wearing rubber gloves. 

137. General anesthesia is necessary in the performance of the 
majority of operations and is of great advantage in all. In the virgin, 
in nerv^ous patients, or those in whom the abdominal and pelvic organs 
are very tender from the presence of inflammation, the administration 
of an anesthetic renders an examination much more satisfactory to the 
physician and less distressing to the patient. For an examination, the 
patient should not be long under the influence of an anesthetic nor should 
she have a large quantity administered. Ether and chloroform are ob- 
jectionable, I. because of the length of time required to secure insensibility 
and recover consciousness; 2. the subsequent nausea and vomiting, 
which frequently last for hours. Nitrons oxid gas is an agent w^hich 
produces prompt unconsciousness, and from which the patient as 
promptly recovers, but it requires a special, quite expensive, and rather 
unwieldy apparatus. 

Bromid of ethyl is almost as rapid in its effects as the nitrous oxid, 
requires but a small quantity, the patient regains consciousness almost 
immediately after the inhalation is discontinued, and its use is much 
less frequently followed by nausea and vomiting. It can be administered 
in one's ofi&ce, and the patient, shortly after return to her home, feels but 
little the worse for her experience. This agent is very satisfactory for 
short operations, such as opening abscesses, or dilatation of the urethra 
or anus. In very nervous patients it may precede the administra- 



1 66 GYNECOLOGY. 

tion of ether or chloroform, whereby the stage of excitement and 
strugghng is avoided. Its principal disadvantage is a pronounced gar- 
licky odor to the breath which continues for several days after its admin- 
istration. 

With Dr. P. B. Bland, during 1 902-1 903, I made some experiments 
with chlorid of ethyl and was much pleased with its action in producing 
quick anesthesia. I employed it for anesthesia in a number of serious 
operations In one patient I did a hysterectomy under its use, the time 
for anesthesia being fifty minutes, without any unpleasant symptoms. 
With a suitable inhaler it was effectually employed with the administra- 
tion of a very small amount of the agent. It did not seem to produce 
any uncomfortable sensations following the operation, although the 
anesthesia was not so profound and durable as that induced by other 
anesthetics. The death of a patient under its administration for the 
insertion of laminaria tents led me to discontinue its use. For prolonged 
operations ether and chloroform are to be preferred. Ether is generally 
recognized as the safer drug. In the very young or the aged it is less 
satisfactory than chloroform, and probably not so safe. Chloroform 
should be preferred in the presence of renal disturbance and when the 
patient is suffering from emphysema or chronic bronchitis. Some of 
the French surgeons advocate the administration of 1/6 of a gr. of sul- 
phate of morphin and i/ioo of a gr. of sulphate of atropin hypodermic- 
ally about twenty minutes prior to the administration of chloroform, and 
they claim: (i) that it increases the safety by diminishing the danger of 
syncope; (2) that the patient is much less likely to suffer from nausea 
and vomiting; (3) that the patient, having taken a smaller amount of 
the vapor, recovers consciousness more quickly. 

Scopolamin-morphin narcosis was advocated by Schneiderlin in 1900 
as a means of rendering patients sufficiently insensible to pain to permit 
the performance of the various surgical procedures. For a time it was 
used extensively. Korff, who administered the combination in two 
hundred cases, advised scopolamin hydrobromate i/io milligram, 
with morphin sulphate 25 milligrams, divided into three doses to be 
given hypodermically, three hours, one and a half hours and half an hour 
before the operation. The first dose rendered the patient drowsy, the. 
second put her to sleep and the final one rendered her insensible to pain. 
Scopolamin-morphin narcosis was advocated as lessening the danger of 
anesthesia. The employment of such a combination of drugs, though 
capable of rendering the patient unconscious for hours, cannot be con- 
sidered as free from danger. The results seem to show that the proce- 
dure should be avoided in persons with weak vessels and enfeebled heart 
action. 

It was claimed that the preliminary administration of i/ioo grain 
of scopolamin hydrobromate with 1/6 grain of morphin enabled the 
administrator to give less of the ordinary anesthetic and diminished the 
the postoperative nausea and vomiting. The experience of nearly one 
hundred cases at Jefferson Hospital clinic has demonstrated that more 
patients suffer from nausea and vomiting after this procedure than when 



THERAPEUTICS. 



167 



ether is given alone. The only advantage which I would concede is that 
where the patient is nervous and fearful of the operation she is so drugged 
before she comes to the operating room that she is oblivious to every- 




FiG. 145. — White's Oxygen Apparatus, which can be Utilized for Anesthesia by Placing 

Anesthetic in the Bottle. 

thing and takes the anesthetic more easily. The same objection applies 
to the morphin-hyoscin-cactin combination. The administration of a 
mixture of chloroform and oxygen obtained by passing oxygen through 
a bottle of chloroform to the inhaler, decreases the danger of this agent 




Fig, 146. — Northrup's Apparatus for Administering a Mixtui-e of Chloroform 

and Oxygen, 

and accomplishes anesthesia with the minimum quantity of the drug, 
without discomfort, with lessened nausea, and with slight subsequent 
distress. (Fig, 145 and 146.) The patient does not have the blanched 



I 68 GYNECOLOGY. 

appearance of the face, and rapidly recovers when its administration is 
suspended. 

For administration, the patient should be placed in a comfortable 
position, the head low, the clothing loosened about the waist and neck. 
False teeth and foreign bodies are removed from the mouth. She should 
be reassured by the physician both in speech and manner, and be directed 
to breathe deeply. Talking on the part of the administrator or attendants 
should be avoided. The pulse, respiration, and condition of the pupil 
should be observed continually. Dilatation of pupils, blanching of the 
face, arrested or stertorous breathing, and sudden feebleness of the pulse 
indicate the temporary withdrawal of the vapor. Continued syncope, 
particularly in chloroform narcosis, requires resort to artificial respiration 
— often suspension of the patient head downward. The administrator 
of the anesthetic should be provided with a hypodermic syringe, solutions 
of strychnin and atropin, and some nitrite of amyl. The latter agent is of 
advantage because of its rapid action as a primary heart stimulant, and its 
influence in dilating the arterioles by action upon the vasomotor system. 
When chloroform is given largely, a mask and bellows, by which the 
lungs can be inflated with air, not infrequently will be effective in saving 
life. In suspended respiration forcible pulling upon the tongue acts as a 
respiratory stimulant. The inhalation of vinegar following anesthesia 
appears to lessen the tendency to nausea. 

138. Local Anesthesia. General anesthesia is attended with 
danger in renal disease, in marked pulmonary changes, in fatty degenera- 
tion of the heart, and in atheroma of the large vessels. In cases, when 
general anesthesia is objectionable, local anesthesia may be employed. 
Freezing by ice and salt, by ether, or by ethyl chlorid spray may be 
utilized, but its application is limited. Continuous irrigation with carbolic 
acid has a benumbing effect upon the mucous surfaces, by which pain 
is obtunded. 

The most effective agent for local anesthesia is one of the cocain salts. 
In operations about the genitals or anus it is given hypodermically 
preferably, and for this purpose the phenate of cocain is the most satis- 
factory. It is slower in being absorbed, and less likely to be a source of 
infection from the presence of micro-organisms. Some have advocated 
eucain in preference to cocain, as it is less volatile and hence more readily 
sterilized. It is also less likely to cause depression. Stovain, a synthetic 
preparation, is claimed to be free from the depressing and toxic effects 
incident to cocain. Injections should be made with a i or 2 per cent, solu- 
tion, using as much as from one to three grains of the drug. The injection 
produces anesthesia for the distance of half an inch from the point of 
the needle; consequently a number of injections may be required. This 
method of anesthesia has been effective in amputation of the cervix, 
trachelorrhaphy, and operations upon hemorrhoids and fistula in ano. 
The drug sometimes has an alarmingly depressing effect. This symptom, 
it is said, may be avoided by combining nitroglycerin in the injection. 
When symptoms of depression occur, resort should be had to strychnin, 
atropin, alcoholic preparations, and nitroglycerin. 



THERAPEUTICS. I09 

Schleich, of Germany, after considerable experimentation, has sug- 
gested three solutions for infiltration anesthesia. The basis of all is a so- 
lution of two parts sodium chlorid, one-fourth part morphin hydrochlo- 
rate, in water one thousand parts, to which, for w^hat is called the stronger 
solution, two parts cocain hydrochlorate are added — one part for the 
medium and one-tenth part for the weaker solution. The water and 
salt are sterilized by heat. A larger syringe than usual is used. The 
site for operation is cleansed carefully; then, after numbing the surface 
with an ethyl chlorid spray, a puncture is made and fluid injected 
until a wheal the size of a dime is raised; the needle is introduced 
in its margin, and so continued until the entire length of the pro- 
posed wound is completed. The same effect can be secured by 
using a long needle and moving it along just beneath the skin, for the 
required distance, as the injection is given. This procedure secures 
anesthesia with a single insertion of the needle. The first puncture is 
the only painful one. The insensibility of the skin lasts from fifteen to 
twenty minutes. 

139. Spinal anesthesia is secured by the injection of one to two 
grams of a sterilized (2 per cent.) solution of cocain into the spinal cavity. 
The injection is made between the lumbar vertebrae and on a line level 
with the crests of the ilia. A long needle is introduced. Its entrance 
into the spinal canal is indicated by the escape of spinal fluid. This 
form of anesthesia has been largely practised by Tuffier, of Paris, who 
observed no untoward symptoms and found it very satisfactory in all 
operations below the diaphragm. 

In a patient who had one kidney removed and the remaining one so 
diseased as to render the employment of a general anesthetic unwise, 
I used this method to open a sinus which extended down to the vertebrae 
and into the pelvis without pain to the patient, nor the depression and 
horrible nausea which had been associated with her previous operations. 
A second patient, a young girl, had a large necrotic ovarian cyst, a portion 
of one lung consolidated, and a mitral murmur wdth beginning cardiac 
insufficiency — factors which made her condition very unfavorable for 
ether or chloroform narcosis. Spinal anesthesia was employed. I was 
able to remove the tumor without pain, and the patient had an uninter- 
rupted recovery. 

I have employed spinal anesthesia in a large number of cases with 
satisfactory results. I use it invariably when I regard general anesthesia 
undesirable because of serious cardiac, pulmonary or renal lesions. That 
such use must necessarily increase the number of cases in which its ad- 
ministration will be followed by fatal results should be considered in 
making up statistics of its gravity. 

140. Preliminary Details of Operation. The presence of the 
anesthetized patient in the operating room^ presupposes the thorough 
preparation detailed in the preceding paragraphs. A sufficient number 
of well-drilled assistants should have their duties assigned, so that the 
operation may proceed without confus "on or delay. The ne cessary instru- 
ments, ligatures, dressings, sterilized water and sponges have been pre- 



lyo GYNECOLOGY. 

pared. In abdominal operations the number of sponges or pieces of 
gauze should be known, so that they may be accounted for before the 
wound is closed. It is also important to have a definite number of instru- 
ments, as both sponges and instruments, especially hemostatic forceps, 
have been left in the abdominal cav ty. Every step of the operation, 
to the minutest detail, should be conscientiously watched, for, as the chain 
is only as strong as its weakest link, so an otherwise perfect aseptic pro- 
cedure may fail through a single flaw. I have seen, after the most careful 
preparations for an operation, the operator place his silk sutures upon 
a syringe box; an assistant stroke his mustache, or a nurse use her hand- 
kerchief, or stroke her hair, each instance being a break which imperils 
the result. 

141. Arrangement. The instruments should be placed at the 
right of the operator, so that he can reach them as needed. The sponges 
should be in the care of a nurse upon the opposite side. The sponges 
or gauze pads should be removed from the receptacle and passed 
with a pair of forceps to the operator or his assistant by the nurse. After 
being used they should be placed in a basin. The nurse dispensing the 
sponges should keep an accurate account of the number given out, with 
which those returned should correspond. The wound should not be 
closed until it is certain all sponges have been removed. It is well to 
have one large, broad piece of gauze for walling off the intestines, or 
several smaller pieces may be employed and the end of each secured 
with a pair of forceps. A basin of sterilized hot water should be 
alongside the instruments for the hands of the operator, and his principal 
assistant should have another. 

142. Positions of Operator and Assistants. In an abdominal 
section I prefer to stand on the patient's left, with my assistant opposite; 
the second assistant gives the anesthetic; a third looks after the instru- 
ments, ligatures and sutures. One nurse attends to the sponges, a second 
is ready for any emergency and counts the sponges after they have been 
discarded, which count should tally with the one made by the nurse dis- 
pensing them. Where the condition of the patient is a grave one, it is 
advisable to have an assistant and nurse ready to employ intravenous 
saline transfusion should it be indicated. 

143. The patient's clothing should be removed in order to prevent 
its becoming soiled during the operation. Separate and clean blankets 
should be wrapped about the upper part of the body and lower extremities. 
These should be covered with sterilized towels, and over all a sterilized 
sheet, in the center of which an opening has been made to expose the 
field of operation. 

144. Incision. The linea alba is chosen for the site of incision in 
the majority of cases of abdominal section. A cut, varying in length from 
two to twelve inches, according to the condition for which the operation 
is done, is made with a sharp knife. When the abdomen is moderately 
distended with a growth, the first sweep of the knife should reach the 
fascia over the peritoneum. The operator and his assistant with long 
dissecting forceps pick up the peritoneum and cut it between them, thus 



THERAPEUTICS. 



171 



avoiding injury to the cyst, or, when the abdomen is undistended, a 
knuckle of intestine. 

As soon as the peritoneum is opened, the atmospheric pressure 
carries the intestine out of the way, when the incision may be completed 



NURSE lA/lTH 
SPONGES 




Operating F^M 

FROM ^BOl/E^ 




NURSE AT 
/NSTRUMENT 
TABLE 



Fig. 147. — Arrangement of Tables and Assistants in Operating Room. 



with a knife or with probe-pointed scissors, introducing two fingers 
as a guard. Should considerable bleeding occur after the first sweep 
of the knife, it can usually be controlled by pressure with a gauze pad. 
When this is insufficient, the bleeding vessels should be seized with 
hemostatic forceps. 



172 



GYNECOLOGY. 



The length of the incision has been a proHfic source of discussion. 
It has but little influence upon the result. It should be sufficiently long 
to permit the object of the operation to be accomplished with ease and as 
little irritation as possible. A long incision, if properly united, will be 
as firm as a short one. 

A combined transverse, or better, crescent-shaped and vertical in- 
cision, was reported at the International Congress on Obstetrics and 
Gynecology, held in Geneva in August, 1896, also described in a paper 
by Kiistner in an article in September of the same year, and has been 




Fig. 148. — ^Abdominal Wall Incised; 
Peritoneum Picked up by Dissecting 
Forceps. 



Fig. 149. — Peritoneum Incised. 



largely practised by Stimson and Cumston in this country. It consists 
of a cresent-shaped incision just above the symphysis, and, where possible, 
confined to the hair surface. It extends through the skin, superficial 
fascia, and aponeurosis. These tissues are drawn up, separating the 
aponeurosis from its attachment, to the pyramidalis muscles. The 
rectus muscles are separated in the median line, and the peritoneum 
incised vertically. This incision permits free access to the pelvic viscera 
and is satisfactory unless a large growth is present which will require a 
longer incision. The advantages of the procedure are that the subsequent 
growth of the hair hides the incision; the probability of hernia is lessened, 
as the suture closing the peritoneum and muscle wall is at right angles 



THERAPEUTICS. 



173 



to that of the aponeurosis. The disadvantages are : the increased bleeding 
from cutting across vessels and the inability to avoid always the occur- 
rence of hematoma either below or above the aponeurosis. Where there 




Fig. 150. — Crescent Incision Exposing Aponeui 




Fig. 151- — Aponeurosis Excised, Showing Pyramidalis Muscles. 

is much disposition toward oozing, it is better to insert one or two small 
drains for the first two days. 

145. Adhesions. In inflammation complicating a cyst it may be 
difficult to determine when we are through the peritoneum. In case of 



174 



GYNECOLOGY. 



doubt it is better to continue the incision until the cyst is opened, when the 
line of union can be determined more readily. It is well to remember 
that at the umbilicus the peritoneum is united closely to the overlying 
tissue, and this fact may be utilized in cases of uncertainty. As far as 
possible, separation of adhesions should take place under the eye, by 




Fig. 152. — Scalpels. 

drawing them down to the incision. Vascular adhesions and every 
bleeding vessel should be secured with forceps or should be ligated. 

With the application of forceps the number of necessary ligations 
will be reduced, as often the pressure will prevent bleeding subsequently. 
All large bleeding points should be secured by ligature before the wound 
is closed. In short, firm intestinal adhesions the greatest safety is assured 
by keeping close to the cyst. In some cases it may be necessary to cut 




Fig. 



-Pressure Forceps. 



into the cyst, leaving a portion attached to the intestine, always taking 
the precaution, however, to remove its inner, secreting surface. Fre- 
quently the worst adhesions the operator will meet are associated with 
infective processes in the tubes, or ovaries, or in relation to myomatous 
growths of the uterus. In both of these conditions the adhesions may 
be so firm as to require the use of the scissors for their separation. All 




Fig. 154. — Long Bladed Dissecting Forceps. 

bleeding vessels should be secured and where possible the raw surfaces 
sutured. 

146. Toilet of the Peritoneum. In the removal of large cysts care 
should be exercised that their contents do not escape into the abdomen. 
If the contents are uncontaminated, consisting of thin serous fluid, 
they should be removed by sponging only. It is diflicult for me as an 



THEIL4PEUTICS. 



175 



operator to get over early impressions. My education leads me to resort 
to abdominal irrigation, preferably with normal salt solution, whenever 
infection is possible, but experience has demonstrated that patients do 
equally well when pus is sponged out with dry gauze pads. Without 
do\ bt, wherever it can be done, the general surface should be protected 
by gauze packing. This will prevent the necessity of extensive cleaning. 
It is a serious question whether the measures we often institute in the name 
of toilet of the peritoneum are not more prejudicial than helpful. When 
irrigation is done, it is most effectively accomplished by pouring the belly 
full of normal salt solution, churning it about, pressing it out, and remov- 
ing the remainder with sponges. All bleeding points must be secured. 




Fig. 



-Glass Drainage-tubes. 



If there is oozing from the surface, sponges wrung out of hot water should 
be packed firmly upon it until the operation is completed, when they can 
be removed. If bleeding still continues, the surface should be sponged 
with a hot solut'on (lo per cent.) of ferripyrin, sprayed with a 4 per cent, 
solution of antipyrin, or infiltrated with a solution of one part (1:1000) 
adrenalin chlorid to three parts sterile water, or the latter may be sprayed 
forcibly against the bleeding surface. Should hemorrhage be persistent, 
a gauze pack affords an efficient means of control. 

147. Drainage was formerly a momentous question. 

Keith's rule that it should be used only when there was something 
to drain was a good one, but with improved methods of technic we can 




Fig. 156. — Uterine Syringe for Cleansing Drainage-tube. 



depend more and more upon the natural absorptive power of the perito- 
neum. The use of the glass drainage-tube, which was formerly a matter 
of routine, is now more honored in the breach than in the observance. 
When a glass drainage-tube is used, it should be from six to eight 
inches long, with a number of small perforations at the lower extremity. 
These openings should be small, otherwise portions of intestine or omen- 
tum slip into them and become strangulated or render the removal of 
the tube painful and difficult The openings should be smooth, and 
beveled at the expense of the outer surface. The lower end of the tube 
should be open; the external end should be provided with a flange, over 



176 GYNECOLOGY. 

which a piece of rubber dam may be placed to prevent soiling the dress- 
ings. The caliber of the tube should not exceed one-third of an inch. 
The use of the drainage-tube required most exacting care upon the part 
of the nurse and physician. Every precaution had to be exercised to 
prevent its becoming a gateway for infection. It needed cleansing 
every half hour or oftener so long as there was any discharge. This was 
accomplished by the use of a suction tube which reached to the bottom 
of the tube, or, better, by tube forceps and pledgets of sterilized absorbent 
cotton. By either method in spite of every precaution, micro-organisms 
in large number found ready entrance. The frequent cleansing of the 



Fig. 157. — Tube Forceps For Cotton Pledgets. 

tube was avoided by passing a strip of sterile gauze to its bottom, which 
acted as a wick. 

Objections to the glass drain arose because: (i) It obliged the 
patient to remain upon her back; (2) unless carefully placed it caused 
sufficient pressure upon the rectum to produce ulceration or even a fecal 
fistula; (3) it increased the difficulty in maintaining the wound aseptic, 
and afforded ingress to pathogenic germs, either through its cavity or 
along its^sides; (4) it rendered the abdomen weak and increased the dan- 
ger of ventral hernia; (5) there was danger of the formation of a sinus 
which was long in closing. It was found the frequency with which 
drainage was thought to be required could be lessened by the introduc- 




FiG. 158. — Gauze Wick in Drain. 

tion of large quantities of normal salt solution. This diluted the infectious 
material and rendered it more readily controlled by the peritoneum. 
Later experience has demonstrated that such cases do equally well by 
carefully walling-off pus collections with gauze before they rupture and 
then thoroughly removing the pus and blood with dry gauze. The per- 
itoneum, if given an opportunity, will take care of infection; the means 
used for the removal of infection cripple the antagonistic processes of the 
peritoneum. Where drainage is deemed advisable, it should be used in the 
great majority of cases through the vagina, either by a twist of gauze or a 
split rubber tube. 



THERAPEUTICS. 



177 



Gauze Dram. Drainage has been accomplished by a twist of gauze, or, 
where there was much oozing, by gauze pressure. The Mikulicz drain 
consisted of a piece of gauze within which strips of gauze were packed. 
A string was tied to its center, and it was placed in the bottom of the 
pelvis. The strips ordinarily were marked, to designate the order in 




Fig. 159. — Mikulicz Drain. 

which they were introduced. The pain in removing was greatly decreased 
by covering the drain with rubber tissue except at its extremity. Drainage, 
whether by tube or gauze, is of but short duration, and its influence is 
confined to a limited area. Lymph exudate soon walls it off as a foreign body 
from the general cavity. Gauze is very efficacious as a tampon. Its 




Fig. 160. — Gauze Drain Covered with Rubber Tissue. 



pressure arrests hemorrhage and promotes the formation of exudation, 
which closes oozing vessels and bars the avenues of infection. 

Where Placed. The drain, whether glass tube or gauze, was gener- 
ally placed in the lower angle of the wound, though it could be placed 
between sutures at whatever part of the wound was most favorable. 



178 GYNECOLOGY. 

As has been mentioned, where possible, it should be through the vagina, 
for the strength of the abdomen is not weakened then. 

Postural Drainage. The uninjured peritoneum is an actively 
absorbent surface. Clark utilized the knowledge of this fact to avoid the 
introduction of a drain by elevating the foot of the bed eighteen inches for 
twenty-four to thirty-six hours. The fluid gravitated away from the injured 
surfaces. The danger of infection was lessened by active irrigation with 
a large quantity of normal salt solution before the wound was closed. 
The activity of any pathogenic material remaining within the abdomen 
was diminished by dilution through the retention of a considerable quan- 
tity of the solution when the wound was closed. 



Fig, 161. — Curved and Straight Needles. 

This position also decreases the pain following an operation by the 
lessened quantity of blood sent into the vessels of the elevated pelvis. 
The pendulum has now swung backward, and we elevate the upper part 
of the body and favor the accumulation of fluid in the pelvis, from which 
it is removed by gauze wicks through the abdominal wound, or, better 
still, by an opening into the vagina. The latter channel of egress should 
be employed whenever possible, because it favors by posture the evacua- 
tion of the most dependent portion of the tract and the danger of sinus 
or hernia is lessened. 



Fig. 162. — Needle Forceps. 

148. Closure of the Wound. Before sutures are introduced, the 
omentum is generally drawn over the intestines. Formerly, when ex- 
tensive adhesions or purulent discharges were present, the belly was left 
filled with a sterile normal salt solution. While we now urge the dry 
gauze sponge, it is difficult not to resort to the flushing with the normal salt 
water when abscess cavities are ruptured. The wound can be closed 
with through-and-through interrupted sutures or buried sutures in separate 
layers. Interrupted sutures of silk, silkworm gut, silver wire, or chromic 
catgut are introduced through the entire thickness of the abdominal wall, 
about three-fourths to one inch apart, including one-eighth of an inch of 



THERAPEUTICS. 



179 



the peritoneal and one-fourth of the skin surface on each side. Each 
suture is secured with a pair of hemostats. After all are introduced, the 
gauze pad placed over the intestines is removed, the cavity inspected, and 
the sutures tied. Care must be exercised that a knuckle of intestine or a 
piece of omentum is not caught by the sutures. The most important 
consideration for the future of the patient is the union of the aponeurosis, 
for upon its accurate union depends the subsequent strength of the ab- 
dominal wall. 




Fig. 163. — Peritoneum Nearly Closed 
with Continuous Catgut. Silkworm- 
gut Sutures through all Structures 
above Peritoneum. Aponeurosis 
Being United with Continuous Suture 
of Catgut. 



Fig. 164. — Silkworm-gut Sutures Tied. 



While the above described single suturing for all the structures will 
often afford a good wall, it too frequently results in a weakened ventrum 
which gives way with increasing corpulence and becomes the site of hernia. 
After many trials with different methods of suturing I have accepted the 
following routine as affording uniformly the best results: Begin external 
to the aponeurosis at the upper angle of the wound; carry a No. i chromic 
catgut suture through all the tissues below the aponeurosis at the right 
side of the wound, secure the end of the suture by hemostat, and ask the 
assistant to maintain at least three inches of it externally. With tissue 



l8o GYNECOLOGY. 

forceps pick up and pass the suture through the peritoneum only upon the 
left side. The subsequent turns of the suture are confined to the perit- 
oneal margins of the wound until the lower angle is reached when the 
suture is brought through the aponeurosis at the left side of the incision. 
(Fig. 163.) With the Reverdin needle silkworm-gut sutures are 
now passed about one-half to three-fourths of an inch apart through 
all the structures above the peritoneum, and the ends secured with 
pressure forceps. After drying the surface, begin at the lower angle 
of the wound with the remaining portion of the catgut suture, which 
closes the peritoneum, and return closing the aponeurosis only, until 
the upper angle is reached, then tie to the end at the right side 
of the wound. This method insures the accurate apposition of the 
aponuerosis and the restoration of the rectus to its normal sheath. 
The silkworm-gut sutures are now tied with moderate pressure, in- 
suring the obliteration of dead spaces, and the muscle surface of the 
wound is placed in a splint until the union can be secured. The ends 
of the silkworm-gut sutures should be left long, as thus they promote drain- 
age from the wound and facilitate their removal. Between each of these 
sutures the skin edges should be approximated by a plain catgut suture. 
These sutures can be sponged away when the silkworm is removed. The 
combined cresentic and vertical incision is closed by a continuous suture 
for the vertical incision, which, beginning above, external to the muscle, 
takes up the peritoneum only until the lower angle is reached. It then 
emerges through the rectus and returns through the edges of these muscles 
until the upper angle is reached where it is tied to the starting end of the 
suture. This suture of chromic catgut is drawn only sufficiently tight 
to hold the surfaces in apposition. A second continuous suture brings 
into apposition the edges of the aponeurosis. A third of plain catgut will 
hold in contact the skin edges. This suture can be sponged off at the first 
dressing ten days after the operation. It may be subcuticular but a 
continuous suture through the skin edges, unless drawn tightly, is equally 
efficient and more quickly introduced. The skin edges accurately 
apposed and the incision confined to the hair surface, the scar is completely 
obscured in a few months. Great care must be exercised to control all 
bleeding vessels, and, where there is a disposition to oozing, drainage 
should be installed to prevent the formation of a hematoma and its sub- 
sequent infection. 

149. Dressing. After the wound is closed it is washed with alcohol 
and a sterile towel is pressed upon it, while the remaining surface of the 
abdomen is being cleansed and dried. The wound surface should be dressed 
with several layers of plain sterile gauze. When the sutures are left 
long, the first pieces of gauze should surround them and remaining portions 
be placed over the ends. The gauze should be covered with a pad of 
gauze and cotton or wood wool. The dressings are held in place with 
tapes attached to pieces of plaster, three on each side, and, finally, a steril- 
ized bandage. The use of the tapes affords a ready access to the wound 
without annoyance to the patient. 

150. Postoperative Treatment. Too often, both by the laity and 



THERAPEUTICS. l8l 

the physician, the struggle for life is regarded as won when the operation 
has been completed, although in many cases this period but indicates the 
beginning of a grave battle. It is true that much may be done to lessen 
the trials of the after-period by careful study and preparations of the patient 
for operation, by the greatest expedition in the operation consistent with 
the most conscientious discharge of every detail of the procedure, the 
limitation of the amount of the anesthetic, and the early and careful regu- 
lation of the circulation. After the operation has been begun or is half 
completed is no time for the surgeon to stop and hold a consultation as to 
what shall be the next step. He must have prepared himself by study, 
meditation, and experience for every possible complication and be ready 
to meet it when it arises. Postoperative or after-treatment comprises the 
consideration and exercise of those details which promote comfort, 
advance convalescence, and further the restoration of the individual to 
normal health. Much of this work the surgeon must delegate to attend- 
ants, but they must be governed by his watchfulness and advice. He 
should not fall into the habit of a routine treatment, nor allow others to, 
but should meet the necessities of the individual case. 

Under the old method of treatment where many cases had a glass 
drainage-tube inserted, it was necessary that the patient should be re- 
strained to the dorsal position. Unless the patient is exceedingly nervous, 
very restless, apparently suffering intense pain, it is better to give no ano- 
dyne. When she is nervous, or complaining, an enema of tincture of 
valerian f3ii-iv, with tinctura opii deodorati gtt. 20 to f5j may be 
given, diluted by §ii salt solution. 

151. Comfort of Patient. The patient is transferred from the 
operating to the private room, where she is placed in bed, covered warmly, 
protected from draft, and kept quiet; the room should be darkened. If 
the operation has been protracted or the patient is depressed, hot-water 
bottles should be placed about her to maintain the body heat. These 
bottles should be corked tightly and a blanket should be placed between 
them and the skin. The patient, unable to understand or to make 
known her discomfort, may be badly burned if such precautions are not 
exercised. It should be recognized that the patient when profoundly 
shocked has a lowered resistance, which will cause her to burn at a lower 
temperature than would occur in health. As she recovers, it becomes very 
irksome to remain in one position. An attentive nurse can greatly add to 
her comfort by passing her hands under the patient so that the cool air 
reaches the heated back, by changing her from one side of the bed to the 
other, and by keeping the clothing under her smooth and dry. Unless 
there is some special contraindication, as the presence of a drainage-tube, 
she may be turned upon her side. Indeed, the early and frequent turning 
of the patient will prove beneficial. It promotes peristalsis, favors the 
early passage of flatus, and lessens the danger of unfortuate intestinal 
adhesions. The nurse should support the patient's back and limbs with 
pillows. One of the earliest symptoms of which the patient complains 
is intolerable thirst. It is better to limit the quantity of liquid for the first 
few hours to small quantities of hot water — a half ounce every hour, given 



l82 GYNECOLOGY. 

with a horn spoon, as the china cup would burn the Kps. Ice should not 
be given; it increases the thirst and the patient will not be contented with- 
out a piece constantly in her mouth. Both mouth and stomach soon be- 
come irritated. When the patient does well, she can have a cup of 
tea or coffee on the morning following the operation, small quantities of 
ice-water or soda-water, equal parts of effervescent vichy and orange-juice, 
a teaspoonful of beef -juice every three hours; and on the second day light 
food, and by the end of the week a generous diet. 

152. Vomiting is likely to follow the anesthetic, the early administra- 
tion of liquids or food by the stomach, or it may be the precursor of per- 
itonitis. Its occurrence should be an indication to discontinue everything 
by the mouth. Enemas of warm water, six to eight ounces, may be given 
to assuage thirst, and when the patient is in need of nourishment, nutrient 
enemas may be given every three or four hours. Nausea and vomiting 
occur very frequently after an operation and may continue several days. 
The ejected material may be the fluid which has been ingested, or bile, 
mucus, or the contents of the small intestine. The application of a mus- 
tard-plaster and an enema of 30 grains of chloral and i dram of potassium 
bromid in 2 ounces of warm water will often be sufficient to quiet the irri- 
tability. If the patient is constantly retching, it is better to give a large 
draft of water with i dram of bicarbonate of soda, a cup of weak tea, or 
some soda-water. 

Professor Hare has suggested 2 grains of acetanilid and 1/2 of a grain 
of caffein citrate, to be repeated in two hours. I have found this formula 
of advantage in vomiting following etherization. Other remedies of more 
or less value are: cocain (4 per cent, solution), 3 drops every hour; tincture 
of nux vomica, 2 drops every hour; 2 drops of compound tincture of iodin 
and 1/8 of a grain of carbolic acid every hour; or i drop of Fowler's so- 
lution every half hour. The earlier the bowels can be evacuated, the 
sooner will the offensive material be removed; Jtience the most effective 
treatment will be the administration of a saline, or, when it cannot be 
retained, the use of calomel alone or in combination with bicarbonate of 
soda (gr. j-ij of the latter to from 1/6-1/4 gr. of the former) every fifteen 
minutes until gr. j-iss of calomel are taken, when magnesium sulphate i 
dram in syrup of ginger and cinnamon water is given every hour until the 
bowels are moved. In frequent vomiting a seidlitz powder is very efficient, 
for if vomited, it generally empties the stomach, and when retained, 
starts the current through the canal. The powder should not be given in 
the usual manner, but the sodium carbonate portion should be dissolved 
in water f giij, the smaller or tartaric acid powder dropped upon this dry 
and given immediately. Th patient should be encouraged to retain this 
as long as possible. If vomited, the stomach is well cleansed and gener- 
ally a portion of the drug passes the pylorus to exercise a good influence 
upon the intestine. A second powder may be given in the same manner a 
half hour later if the first is ejected. 

If the intestine is distended and has not yielded to enemas or to the pur- 
gatives suggested, and the patient is constantly vomiting small quantities 
.of dark fluid, nothing will give quicker or more lasting relief than irriga- 



THERAPEUTICS. 1 83 

tion of the stomach through a stomach-tube. When it is evident that the 
vomiting is an indication of peritonitis, it is wiser to discontinue purgatives 
and be content with lavage. No food, not even water, should be given by 
the mouth, and peristalsis should be arrested by small doses of morphin 
hypodermically. Rectal feeding may be required because of irritable 
stomach and the enfeebled condition of the patient, and especially in 
conjunction with the treatment suggested for peritonitis. 

Peptonized milk or broth may be given every three or four hours. 
When the patient is much depressed, a normal salt solution and whisky 
or bovinin in combination may be given. When rectal feeding is practised, 
the bowel should be irrigated once or twice daily. 

153' Tympanites may be the result of a passive collection of gas 
in the intestines, or may indicate the development of peritonitis. The early 
passage of flatus is always an encouraging symptom. The sensation of 
distention may be promptly met by the use of an enema of 

Magnesium sulph., "1 

Glycerin, } aa B j. 

Water, J 

If relief is not secured, an enema of two tablespoonfuls of turpentine 
beaten up with the yolks of two eggs and strained into a quart of soapsuds 
should be administered. Keith recommeds an enema consisting of 6 
grains of quinin dissolved in 4 drams of whisky and two ounces of 
warm water, to be given every two hours until three doses have been ad- 
ministered. This prescription stimulates the nerve-centers and favors per- 
istalsis. If peristaltic action is marked, but reversed, lavage should be em- 
ployed, a hypodermic injection of morphin given, and followed, after a rest 
of three or four hours, by a repetition of the quinin. The most effective 
agent to influence increased peristalsis is an enema consisting of an ounce 
of powdered alum dissolved in a quart of hot water. 

154. Severe shock should be combated by the use of artificial heat, 
enemas of coffee and stimulants, suppositories of ice, elevation of the foot 
of the bed, bandaging the limbs, and the injection of normal salt solution 
into the buttocks, beneath the scapula, or directly into a vein. A hypo- 
dermic injection of strychnin (gr. 1/30 to 1/6) should be given according to 
the urgency of the condition, and followed by some aseptic preparation 
of ergot. Ergone in 20-minim doses is valuable, or it may alternate with 
(i : 1000) solution adrenalin chlorid, 20 minims every two hours. Atropin 
sulphate (gr. i/ioo) twice daily wfll be servicable in controlling the vessels. 
Where loss of blood has been great, renal secretion arrested, or shock 
profound, the intravenous injection of two to three pints of a i per cent, 
salt solution is the most effective agent which can be employed. 

Immediately after an operation the patient should be isolated from 
anxious friends and disturbed as little as possible consistent with proper 
measures. 

155. Anodynes. The patient should be encouraged to bear pain 
without an anodyne. Moderate distress may be allayed by the rectal use 
of chloral, 30 grains in two ounces of warm water. When the' pain is very 



184 GYNECOLOGY. 

severe, and accompanied with marked restlessness, a hypodermic injection 
of 1/8 to 1/4 grain of morphin may seem the less serious factor. Morphin 
decreases peristalsis and favors tympanites, and consequently should be 
avoided if possible. Whenever it is evident that peritonitis has developed, 
and purgatives are ejected as fast as given, morphin with lavage should be 
considered our sheet anchor and be given for effect, giving an initial dose 
or gr. 1/4 to 1/3, and following with 1/16 to 1/8 every three hours. 

156. Internal hemorrhage, if the technic is perfect, should not occur. 
Its existence will be indicated by paleness of lips, feeble or absent pulse, 
sighing respiration, and clammy perspiration. The use of strychnin 
or the injection of salt solution favors the increase of hemorrhage. The 
only proper treatment is prompt reopening of the wound and ligation of the 
bleeding vessel. 

157. Peritonitis will occur early or late according to the virulence 
of the infection. The aim of the operator, of course, is to avoid the 
possibility of its occurrence, but in many instances the patient may have 
been infected prior to the performance of the operation, when all the skill 
of the operator could not remove the sources of further development. It 
is likely to occur in acute gonorrheal and septic infection of the tubes and 
pelvic structures, in large accumulations of blood, either prior or subsequent 
to operation, which have been infected from their juxtaposition to the 
intestines, and soiling of the peritoneal cavity by the contents of dermoid, 
glandular, and papillary ovarian cysts. Peritonitis is characterized by in- 
creasing tenderness of the abdomen, decreased peristalsis, tympanites, 
frequent vomiting, especially when occurring on the second and third days; 
rapid, feeble, thready pulse, and more or less elevation of temperature. 
The vomited material may be considerable quantities of dark-greenish, bit- 
ter, and ofttimes foul-smelling fluid — apparently more is vomited than the 
patient has taken. The tongue is dry, the patient complains of intense 
thirst, and is constantly crying for water and ice. The administration of 
purgatives in these cases is generally ineffective, for the reason that the 
patient vomits or regurgitates everything as soon as taken. Enemas are of 
little value, as they only empty the lower bowel. The proper plan of treat- 
ment is to wash out the stomach with the stomach-tube, give the patient 
a hypodermic injection of morphin, gr. 1/8 or 1/4, repeating this in doses 
of gr. 1/12 to 1/6 every two or three hours, keeping the patient under its in- 
fluence. As all efforts at increasing the peristalsis are ineffective, we aim 
to place the intestines in a splint, and remove the offensive material from 
the stomach and upper part of the intestine by lavage. Frequently under 
this course we will see patients who seem to be almost moribund become 
quiet, and comfortable, resting easily. After two or three days there will 
be a profuse evacuation of the bowels and the patient go on to recovery. 
The strength of the patient during this period should be maintained by 
hypodermic injections of ergone, strychnin, hypodermoclysis of normal 
salt solution in the breasts and the buttocks and rectal feeding. To place 
the patient in the Fowler position with continuous irrigation of the bowel, 
as suggested by Murphy, will be of great value. If there is reason to 
suppose that an accumulation of fluid within the abdominal cavity has 



THERAPEUTICS. 1 85 

occurred a vaginal incision should be made for its evacuation or the 
abdominal wound reopened and drained by gauze wicks. The instillation 
of salt solutions oss-j per minute will result in free irrigation of the 
peritoneal cavity through such a drain. Having begun this treatment for 
peritonitis the attendant should not be in too great haste to secure an 
evacuation of the bowels, as oftentimes the flame may be relighted by 
the too early administration of a purgative. 

158. Wound Infection. It is the aim of the operator to secure heal- 
ing of the w^ound by first intention. Every safeguard is thrown about the 
operative procedure in order to secure this object. Occasionally, however, 
in spite of all precautions the wound becomes infected from the material 
that is taken out of the abdominal cavity, or in closing the wound a vessel 
is punctured and hemorrhage of considerable quantity takes place into 
the tissues directly over the peritoneum. Even if the depth of the wound 
does not contain pathogenic germs, such an accumulation is likely to be- 
come infected from its close proximity to the intestine, and three to six 
or even ten days after the operation the patient may develop a tempera- 
ture, complain of more or less tenderness over the abdomen and the parts 
will be swollen. Where the abdominal walls are thick it will be difficult 
to recognize and determine the existence of any accumulation. It is 
better, howxver, where careful examination discloses the absence of any 
trouble within the pelvis or other portion of the body to account for the 
elevation of temperature to make an exploratory puncture through the 
structures sufficiently deep to reach the space between the muscle wall and 
peritoneum. If the operator fears to penetrate the peritoneum after 
making the incision through the aponeurosis, he can enlarge the opening 
by introducing a grooved director. The early evacuation of an accumula- 
tion will prevent the suppuration and burrowing of the pus and will pro- 
mote rapid convalesence. The infection in some cases may have been 
carried into the depths of the wound in the removal of the sutures. 

159. Parotiditis. Inflammation of the parotid glands is a compli- 
cation of infrequent occurrence. However, it formerly occurred so fre- 
quently that there was supposed to be some intimate relation between this 
gland and the pelvic structures that caused metastasis of inflammation. 
It is now recognized, however, that its inflammation and infection are due 
only to the fact that this gland is more susceptible to the influence of some 
forms of bacteria than other structures of the body. Then, too, it is recog- 
nized that in the majority of instances the infection reaches the gland 
through the mouth and is due to local rather than general conditions. 
Where the patient is suffering from peritonitis or septic conditions, with dry 
tongue, decreased amount of saliva, the patient should be watched care- 
fully and the mouth kept clean to prevent the entrance of infections to this 
gland. Where the gland shows signs of developing inflammation, the 
most effective treatment is to apply an ice-bag over it at once, keeping 
the ice constantly applied, thus limiting the extent of the inflammatory 
process; where suppuration occurs the pus should be promptly evacuated 
by incision. 

160. Ileus is an obstruction of the intestine that may take place one 



1 86 GYNECOLOGY. 

or more weeks after an abdominal operation. It develops by nausea and 
vomiting. The latter continues with ejections of stercoraceous material, 
intense pain, profound depression, shock, rapid pulse, and haggard, 
anxious expression. If unrelieved, it terminates in the collapse and death 
of the patient. It may be due to paralysis of a portion of the intestine 
from infection; from adhesions constricting and making difficult the pas- 
sage of contents of the intestine through the tract; or twisting of the gut, 
forming what is known as a volvulus or intussusception. If the patient 
is not relieved by lavage and hypodermic injection of morphin, the wound 
should be reopened and the condition overcome. In the majority of 
cases merely opening the abdomen, freeing the adhesions, and reestablish- 
ing the caliber of the gut, will be sufficient to accomplish relief. This 
procedure, however, should be done early, as otherwise the patient will 
be so exhausted that it will be ineffective. 

i6i. Phlebitis generally affects the saphenous vein, sometimes ex- 
tending into and involving the femoral and iliac. This infection may 
occur at a later date in a patient who otherwise has exhibited every indica- 
tion of a normal convalescence. A week or even two weeks after the opera- 
tion has been performed the patient complains of intense pain in the calf of 
one leg, most frequently the left. The pain extends up along the course of 
the vein and most frequently is associated with tenderness over the saph- 
enous, and the iliac veins. The patient should be kept perfectly quiet. 
The limbs should be raised and bandaged. The course of the vein 
should be smeared over first with some ichthyol and belladonna ointment, 
taking ichthyol and extract of belladonna aa 5jj lanolin 5 j, wrapping the 
limb well with cotton, and applying a bandage, making moderate pressure 
its entire length. The limb is then elevated and kept more or less im- 
mobile by placing a sand-bag on either side of it. An ice-bag should be 
applied over the saphenous and iliac veins. Even after the acute symp- 
toms have subsided the patient should be kept in the recumbent position 
and the limb perfectly quiet, as it is impossible to say in any individual 
case what the termination may be. A clot may become organized, 
obliterating the affected vein. It may break down, indicating suppuration 
and the formation of a localized abscess. Fragments of the clot may 
disintegrate, are carried into the circulation, and form emboli, blocking 
up the circulation to important viscera and giving rise to a fatal termi- 
nation. The nutrition of the patient should be maintained to the utmost 
degree. 

162. Precautions in the Use of the Hypodermic Syringe. In the 
use of the hypodermic syringe there are four sources of infection: (i) 
The hands of the operator; (2) the instrument; (3) the fluids to be injected 
and (4) the skin of the patient. The syringe is difficult to keep aseptic. 
The metal instrument may be boiled in a soda solution. If you have a 
glass instrument, the piston should be withdrawn and it and the barrel 
should be placed in a 5 per cent, solution of carbolic acid; the needles, 
if platinum, may be passed through an alcohol flame, but ordinary needles 
would be destroyed, and, therefore, they should be boiled. Solutions of 
atropin, morphin, cocain, strychnin, and ergotin favor the development of 



THERAPEUTICS. 1 87 

bacteria, and when kept for some time, will be found swarming with micro- 
organisms. Cocain may be kept in a (i: 10,000) bichlorid solution; the 
others named may be preserved by the addition of a few drops of carbolic 
acid to the ounce of solution. Probably the safest method is to make up 
the solution of morphin, atropin, or strychnin from tablets, which can be 
dissolved by boiling without affecting the action of the drug. 

163. Catheterization. No procedure, fraught with so much discom- 
fort to the patient when carelessly employed, is so frequently performed 
with little consideration as the use of the catheter. Not only are dis- 
tressing symptoms produced by infection of the urethra and bladder, but 
serious results from extension of the disease to the ureters and pelves of 
the kidneys. Fortunately, the female urethra is short, and permits the use 
of a glass catheter, which can be kept clean. The instrument should be 
scalded before and after being used, and should be kept in a 5 per cent, 
solution of carbolic acid during the interv-als. It should be free from cut- 
ting edges. 

The labia should be separated to expose the urethral orifice, when the 
vestibule should be sponged with a solution of boric acid or sterile water. 
The catheter should be gently introduced being held between the thumb 
and middle finger of one hand, while the index finger is placed over its 
opening to prevent the premature discharge of urine. The instrument is 
carried upward and backward as the patient lies upon her back. When 
it enters the bladder, as is evident by the absence of resistence and the 
appearance of urine in the instrument, its external end should be brought 
over the receptacle between the limbs of the patient. Should the quantity 
of urine be larger than the reservoir will hold, the finger placed over the 
end of the catheter will permit it to be emptied and replaced. The bladder 
can be completely emptied by making pressure over the lower abdomen 
with the unoccupied hand. With the discharge of the last urine the finger 
should be placed again over the end of the catheter to prevent the urine 
flowing over the vulva or soiling the bed. When pressure has been made 
over the abdomen, the finger should be so placed before the removal of the 
pressure as to prevent the aspiration of air into the bladder. Should the 
urethra become painful or irritation of the bladder occur from frequent use 
of the catheter, the bladder should be irrigated with a hot boric-acid 
solution. The urethra should be treated by the instillation of 2-5 per cent, 
solution of argyrol twice daily. After an abdominal operation, the cathe- 
ter need not be used for twelve hours unless the patient experiences much 
distress. 

164. Removal of sutures in an ordinary case should occur from 
the seventh to the tenth day. If the patient has had a complicated con- 
valescence, the union will not be so firm, and it would be better not to re- 
move the sutures until the end of two weeks. If they are pulling and caus- 
ing pain, a part of them may be removed. The same care regarding clean- 
liness and avoidance of sources of infection should be practised as in the 
operation. Leaving the sutures long (see Fig. 92) will facilitate their 
removal and dispense with the necessity for forceps to lift up the knot. 
All the sutures should be cut before any are withdrawn, then the long ends 



155 GYNECOLOGY. 

may be gathered up and, bracing the wound with the fingers of the other 
hand, they may all be withdrawn at once, thus giving the minimum of 
discomfort. The wound should be dressed as in the beginning. 

165. Leaving the Bed. The length of time the patient shall be con- 
fined to bed after an operation necessarily varies with the gravity of the 
procedure. Of late years some operators have advocated getting the pa- 
tient out of bed the second day. This plan may do no injury when the opera- 
tion is a simple one and the incision short; but the majority of patients 
coming to operation will, I am convinced, profit by the rest in bed for a 
longer period during the convalescence. In uncomplicated cases, I allow 
the patient to sit up for a few minutes at the end of two weeks. In com- 
plicated operations or in disturbed convalescence, it is better that the pa- 
tient should be kept recumbent for seventeen to twenty-one days. When 
the patient sits up it should be for but fifteen or twenty minutes, and pref- 
erably in a chair, as the strain is less than if she is supported by a bed-rest. 
The time should be increased daily. 

166. In plastic operations the same precautions as to cleanliness 
must be observed. Sponging can be replaced by the use of continuous 
irrigation. The parts may be dusted with acetanilid or iodoform and 
boric acid. The parts should be dressed with sterilized gauze held in 
place by a bandage. 

Vaginal irrigation should not be practised during the first forty-eight 
hours subsequent to an operation, for it interferes with the sealing of the 
wound by plasma. The patient should be confined to bed at least two 
weeks, and in perineal operations three weeks are preferable. In combined 
uterine, vaginal, and perineal operations the internal sutures, if non- 
absorbable, should remain for three or four weeks. I prefer chromic 
catgut for all plastic work, for the reason that the patient is spared the 
discomfort of the removal of sutures, and the newly united tissues are 
not subjected to the strain. 

FUNCTIONAL DISORDERS. 

167. Menstruation, as the first function of the genital tract to appear, 
necessarily becomes a barometer for determining any disordered action of 
the genital organs. Schaeffer found menstruation occurs in 28 per cent, 
of virgins without disturbing symptoms. Local symptoms appear in 28 
per cent, without serious significance, but in 14 per cent, they are so severe 
as to deserve the designation of pathologic. 

The symptoms most frequently mentioned are exhaustion, sense of 
weight, headache, loss of appetite, and local pain. These are so fre- 
quently associated in varying forms with menstruation as to be known as 
the molimlm menstrualis and are present as: i, local pain; and 2, symp- 
toms in remote organs. 

Local pain results from uterine contractions which are not continuous, 
but vary from cramp-like recurrences to pronounced paroxysms. These 
attacks were formerly attributed to accumulation of blood in the uterus. 
The pain in one-third of the cases is pre-menstrual. In a second third it 



FUNCTIONAL DISORDERS. lOQ 

continues with the menstrual flow. In many cases a sparse menstrual 
flow is associated with agonizing pain. That the entire pelvic organs 
sympathize with the menstrual hyperemia is evidenced by distention of the 
abdominal veins causing a sensation of weight and pressure, heaviness 
and aching of the legs, and frequently varicose veins. 

Symptoms in remote organs are: loss of appetite; nausea and vomiting; 
pressure at the pit of the stomach; salivation; eructations; headache; 
typical migraine; dizziness; distressing sleep; swimming before the eyes; 
noises in the ears; ascending globus; palpitation of the heart; irregular 
pulse; air hunger; mental anxiety; hot flashes; sudden outbreaks of per- 
spiration; shive rings; and cold feet. 

Such psychic phenomena as excitement, depression, variations in the 
voice, in the joy of life, capacity for work, and in the intelligence; hysteric 
and epileptic seizures and choreic attacks were formerly regarded as 
nervous or reflex manifestations. Now we realize that they are largely 
due to the increased arterial tension incident to the menstrual cycle. 
While it is true that the majority of w^omen are to a degree handicapped by 
the occurrence of menstruation, there are some who feel at their best and 
have the greatest capacity for work during the period. 

1 68. Vicarious menstruation is the designation for want of co- 
ordination in the internal secretions or in their action on the vasomotor 
system which leads to local disturbances in the circulation resulting in 
either the discharge of blood or persistent manifestations in the various 
structures of the body. These manifestations may or may not be accom- 
panied with a discharge of blood and affect, in the order or relation. 

1, The mammary gland which becomes swollen, hard, and erected; 
the nipple browned, furnishing colostrum under pressure; with hemorrhage 
from the nipple or a periodic secretion of milk. 

2, The eyes, eyelids, and conjunctiva are affected next in frequency. 
They become injected, present edematous alterations, photophobia, tear 
trickling, herpes, styes, and hyperemia of the cornea. There is increased 
pressure on the eyes, attacks of glaucoma, choroiditis, iritis, and neuritis 
optica. Especially frequent are functional disturbances such as as- 
thenopia, photophobia, limitation of vision field, and exceptionally acute 
vision. 

3, The respiration is influenced as in change in the voice, especially 
marked in singers, actresses, and teachers, who at the time of menstrua- 
tion complain of fatigue and loss of tone. The entire voice organs 
may be congested, with swelling of the glands, especially distention of the 
blood-vessels of the posterior walls of the larynx, which is generally the 
cause of these phenomena. Menstrual herpes of the larynx may be 
observ^ed, various disturbances of the respiration such as aphonia, nervous 
cough, suffocation, deep voice, vicarious hemorrhages from the lungs 
and premenstrual rise in temperature. The latter is an indication of 
tuberculosis. The nose is often the seat of trouble. Swelling of its 
membrane is so frequent that it has led to muscle resection and to galvano- 
cautery operations. Bleeding from the nose is the most common form 
of vicarious menstruation. 



IQO GYNECOLOGY. 

4, The organs of nutrition manifest their association by loss of appetite, 
nausea, vomiting, and diarrhea. I recently had under observation a school 
teacher who had such obstinate nausea and vomiting for a week out of 
each month that she was completely incapacitated for her work. Intes- 
tinal hemorrhages are occasionally seen to supplant the menstrual flow. 

5, Disturbances of the skin are seen in acne of the face, profuse sweating, 
pigmentation of the skin (chloremata uterina) pigmentation of the linea 
alba in young girls, herpetic eruptions, lupus, erythema, purpura, ery- 
sipelas, lichen-like papulous eruptions, and urticaria. 

6, The renal circulation shows disturbance by bloody urine, or 
clayey urine from the increase of phosphates and urates and decreased 
secretion. 

7, Swelling of the thyroid is frequently associated with menstruation, 
especially in women suffering from Basedow's disease. The arterial 
tension associated with menstruation may be so reduced by the loss of blood 
in organs with weakened vessels that it fails to cause the rupture and 
escape of the blood from the genital tract. 

169. Amenorrhea is partial or complete suppression of the menstrual 
discharge in women during the usual period of sexual activity. It may be 
lessened gradually for a period of months, cease suddenly, or may nev€r 
have appeared. It may be accompanied by a cessation of sexual desire, 
myxedema, or obesity. In the latter it is often difficult to determine 
whether the adipose is a cause or the result of the menstrual cessation. 
Among the chronic conditions in which amenorrhea is a symptom are 
long continued catarrh of the stomach; mitral defects; chronic poisoning 
from morphin, alcohol, and phenacetin; and the psychic diseases. Theil- 
haber says that half of all functional psychoses lead to amenorrhea while 
it is rare in the chronic psychoses. 

Amenorrhea is physiologic when due to the occurrence of pregnancy, 
or during the course of lactation; pathologic when the result of well defined 
diseased conditions; Sind functional in those rare cases in which no explana- 
tion can be found in local or general conditions. The most prominent 
causes of the latter are psychic, as fright, an agonizing catastrophe, a con- 
flagration, railway accident, death or news of death, marked joy or sorrow, 
great depression, fear of pregnancy from illicit intercourse, great desire 
for pregnancy, change of climate or of altitude. It may also occur from 
cold, getting the feet wet, cold baths or cold douches during menstruation, 
or from insufficient clothing. Amenorrhea is associated with chlorosis, 
acute and chronic anemia, obesity, and excessive loss of blood in labor or 
childbed. Various infectious processes frequently engender it, and it is 
often associated with the early stages of tuberculosis. Operative amen- 
orrhea is induced by the removal of the ovaries during the age of sexual 
activity, and its manifestations have afforded much information ,in the 
study of this symptom. 

Symptoms: Amenorrhea and cessation of menstruation, known as 
the climacteric, often resemble each other in their manifestations. The 
symptoms may be divided into local or remote, those emanating from 
the genital organs, and those from other organs of the body. The 



FUNCTIONAL DISORDERS. I9I 

symptoms are wanting in congenital aplasia of the ovary. They are 
most marked when amenorrhea is the consequence of closure of some 
portion of the genital canal where the discharge finds no exit. The 
pressure symptoms thus engendered every four weeks often cause the 
most severe and intolerable paroxysms of abdominal pain. While the 
patient experiences all the discomforts of an approaching menstruation 
and the pain just mentioned, there is a suppression of any discharge. 
Generally the condition is attended later with the formation of a pelvic 
or abdominal tumor, the result of the accumulation. The sparse 
and weakened menstruation which differs but little from complete 
amenorrhea appears often with severe cramp-like pain in the abdomen 
and sacrum. 

Amenorrhea is frequently associated with rapid increase of adipose. 
It is questioned whether the adipose is a cause or a consequence of amenor- 
rhea. Doubtless both are due to the defective secretion from the cor- 
pora lutea. Also, as in the climacteric, the patient complains of pruri- 
tus vulvae, colpitis, endometritis atrophicans, and irritable bladder, but 
more frequently of psychic nervous disturbances such as excitement, 
flashes of heat, increased redness, palpitation of the heart and air hunge/; 
of hysterical manifestations such as change of voice, aversion, depression, 
capricious temper, the so-called reflex neuroses, migraine, nervous 
dyspepsia, hiccough, flatulence, insomnia, tingling and numbness of 
the extremities. Disturbances of the skin, of the mammary gland, and 
of vision may be associated with amenorrhea and disappear with the 
recurrence of the menses. 

Where amenorrhea continues, it leads to atrophy of the uterus and 
ovaries and must eventually become incurable. 

Prognosis. In absent uterus and congenital atrophy of the ovaries 
the condition is hopeless. Cases of obstruction of the genital canal afford 
a favorable outlook only where there is the formation of a hematocolpos. 
Its absence demonstrates that the ovarian function is wanting. The 
nonappearance of the first menstruation may be due to the delay of 
puberty rather than to defective development. Schaeffer found that in 
10,500 cases, the first period did not occur until the twentieth year in 
4.09 per cent. Cessation of menstruation from acute infectious cases 
which persists after convalescence would indicate that there had been 
destructive changes in the ovary. In the cases of increased adipose or 
those resulting from chlorosis, often the condition may be overcome 
by judicious care. 

Treatment. When the organs are defective in their development, 
as in rudimentary and misformed, or absent uteri, or in anatomical alter- 
ations of the organs from disease such as cicatricial destruction of the 
endometrium or from ovarian neoplasms, treatment is hopeless. Restor- 
ation of the function is not only useless but positively injurious. An 
obstructive case is generally the most satisfactory, as a simple incision 
may be sufficient. Where atresia is high in the canal, as at the external 
or internal os, with narrowed or absent vagina, treatment may be very 
difficult and complicated. Under such circumstances with an extensive 



192 GYNECOLOGY. 

accumulation it is better to make a small incision. The sudden empty- 
ing of such a sac may lead to rupture of an adherent and distended tube. 
Where amenorrhea exists in organs capable of function, the treatment 
should be directed: i, to increasing the circulation in the genital organs 
in order to overcome defective uterine and ovarian function; and 2, to 
the employment of such means as will improve the general nutrition and 
compensate for the injuries of the amenorrhea. 

1. In the former instance a sharp differentiation should be made 
between a functional amenorrhea and that induced by bodily disease. 
The production of pelvic engorgement would be contraindicated in ir- 
reparable malformations and grave constitutional conditions such as 
tuberculosis and diabetes. The advisability of marriage and the possi- 
bility of conception will have to be considered. 

General hot baths, hot foot and sitz baths, or baths medicated with 
mustard, lye, carbonic acid, or the natural salts may be employed. 
The latter with carbonic acid come in considerable quantities in the 
Kissingen and Nauheim. Hot vaginal douches at 104° to 120° F. act 
by inducing uterine contractions. The cervix may be punctured or 
scarified just before the period should occur. Sounding the uterus may 
be employed in the virgin. The Apostoli treatment may be used by 
inserting the negative pole into the uterus and employing 30 to 60 mil- 
liamperes. The long continued wearing of a stem pessary had been 
found efficacious. Other measures are pelvic massage, Bier's treatment, 
and mustard plasters to the mammary glands. Internal remedies which 
exert an influence on the pelvic congestion are aloes, salycilic acid and 
its salts, salipyrin, potass permanganat, sanatori, and indigo. Apiol in 
nervous and hysterical patients is effective. 

2. When due to constitutional conditions these should receive first 
consideration. Chlorosis should be treated with iron waters, especially 
those containing arsenic. Baths, systematic exercise, and sea-bathing 
are beneficial. When associated with adiposes a carefully regulated 
diet, gymnastics, tennis, golf, out door sports, and saline baths are in- 
dicated. The employment of the animal extracts (thyroid and lecithin) 
are efficacious in vasomotor disturbances. 

170. Menorrhagia. An increase or prolongation of the normal flow 
occurring at more or less regular intervals is known as menorrhagia. When 
the bloody discharge seems to have no relation to the regular period it is 
known as metrorrhagia. It is very difficult to draw a line of demarcation 
between normal and abnormal flow. The maximum quantity that 
should be lost has been placed at 200 grams, but this quantity would be 
excessive for the debilitated woman or one who habitually loses little. 
It is difficult to estimate by the napkins the quantity lost for one will 
wear them until they are saturated, while another will allow them only to 
become stained. Whether the discharge is thick or the fluid clotted is of 
diagnostic value. 

Symptoms. Profound chronic anemia indicated by paleness or sal- 
lowness of the skin, physical and mental weakness are characteristics 
of both menorrhagia and metrorrhagia. 



FUNCTIONAL DISORDERS. I93 

Etiology. The causes of the condition are both local and constitu- 
tional. I. Chief among the local causes is endometritis, interstitial or 
glandular; circumscribed mucous hyperplasia; or mucous polypi. 

Menorrhagia concerns particularly the period of sexual activity and 
may occur soon after puberty, although the greater frequency is near the 
climacteric. Metritis may be associated with the endometritis although 
hyperplasia tends to lessen hemorrhage. Profuse menstruation in 
metritis may be associated with excessive copulation, masturbation, and 
excessive exercise at periods. The submucous and interstitial myomata 
often cause profuse menorrhagia while it will be absent in the subperi- 
toneal. Periuterine inflammations either acute, subacute, or recurring, 
play an important role, but Czempin calls these secondary uterine 
hemorrhages. Uncomplicated ovarian tumors rarely cause increased 
menstruation but it may be produced by torsion of the pedicle and is 
observed when the cysts are malignant. Retroflexion and tubal tuber- 
culosis are factors. Menorrhagia of a particularly obstinate character 
for which no cause can be assigned occurs during the sexual life. The 
mucosa wfll then be found to be atrophied. The condition has been 
variously ascribed to arteriosclerosis, or weakness of the muscle wall. 
The latter in many cases seems to be the proper explanation. 

2. General conditions are chlorosis, chronic anemia, adiposis, and 
occasionally phthisis, although it more frequently results in amenorrhea. 
The acute infections such as cholera, malaria, small-pox, typhoid and 
scarlet fevers, and the chromic poisons as lead and alcoholic are most 
important. Frequent causes are diseases of special organs, as renal, 
cardiac, and hepatic diseases and arteriosclerosis. 

Treatment. Where recognizable, treat the cause by general measures, 
absolute rest, saline purgatives, styptics, and the oxytocics. Ergot, 
hydrastin, stypticin styptol, salipyrin, ipecac, and nauseating drugs can be 
used. Hot vaginal douches 140°-! 20° F. cause uterine contractions. 
Tampons to promote clotting are valuable measures. The reduction of 
arterial tension with nitrates supplemented by tampons is sometimes 
efflcacious. Endometritis is best treated with the curet. Myomata 
and persistently obstinate menorrhagia call for radical procedures. In 
periuterine inflammation the curet should be used only when the abdomen 
is to be opened at the same anesthetization. 

171. Dysmenorrhea. There are few women who do not experience 
more or less discomfort during menstruation but when performance of 
the function is attended with severe often agonizing pain, the symptom 
is denominated dysmenorrhea. Simflar pain is sometimes experienced in 
the intermenstrual period and has been named intermenstrual dysmenor- 
rhea, but such employment of the term is not allowable. It is difficult 
to differentiate typical or essential dysmenorrhea from that which is due 
to diseased conditions. In the former the patient should be free from 
discomfort in the menstrual intervals. It is not unusual to find that after 
marriage a woman who when young did not suffer from dysmenorrhea 
has painful menstruation from gonorrheal or septic infection. 

Diagnosis and Symptomatology. 1. The majority of sufferers from 
13 



194 GYNECOLOGY. 

pelvic disease recognize the necessity for treatment while the sufferer 
from dysmenorrhea feels perfectly well until the advent of the period. 
In the interval no degree of exercise causes discomfort. 

2. The colic-like appearance of the menstruation is characteristic. 
Following brief preliminary manifestations it reaches such a height that 
the patient is incapacitated for any activity. She has her legs drawn up, 
rolls from side to side, and complains of cramp-like pain in the abdomen 
radiating to the sacrum which continues for hours or recurs at trifling 
intervals for one or two days. The pain generally appears before the 
flow and frequently is associated with nausea, vomiting, and severe 
migraine. 

3. The pain may occur with the first menstruation or come later 
and increase with severity. It generally affects the unmarried or nul- 
liparous woman. The typical form not infrequently disappears after 
marriage thus differentiating from the pain following cohabitation and 
its results. 

4. Special sensitiveness to sounding of [the uterus is experienced at 
the external os and the tubal angles. 

Etiology. It was formerly taught that dysmenorrhea was invariably 
the symptom of obstruction but every gynecologist sees cases with pinhole 
OS or very acute anteflexion in whom menstruation occurs almost with- 
out the knowledge of the patient, and other women in whom the process 
is attended with agonizing pain, although the canal is so large there should 
be no obstruction. The hypothesis of Menge is probably the correct one. 
He asserts that the various kinds of dysmenorrhea have so great a sim- 
ilarity in character that they must necessarfly be united in an essential 
cause. He perceives this common cause in the activity of the uterine 
contractions during menstruation. While the established uterine con- 
tractions which occur in every menstruation are insensible in the physic- 
ally and psychically healthy woman they are recognized as labor pains 
in pathologically altered genitalia as well as in functional disturbances 
of the nervous system. In the neurotic and neurasthenic it is often a 
form of fatigue neurosis. Its disappearance after the birth of a child 
or in change of scene is due to a psychic diversion. Membranous or 
exfoliative dysmenorrhea is a form in which there is a more or less well 
formed cast of the uterus thrown off. The separation and expulsion of 
this material whether as a cast or in shreds in attended with agonizing 
pain. 

Treatment. The life of the patient who suffers from this symptom 
must be regulated carefully. During the menstrual intervals she should 
be encouraged to take daily exercise in a gymnasium or in the open to 
harden the body and strengthen the will. During the flow she should 
rest in bed, have the diet restricted, wear loose clothing, retire early, 
and avoid every cause for nerve strain. The aim of treatment should 
be I, to increase the general capacity of resistance and 2, to prevent a 
congested condition and promote the emptying of the overfilled vessels 
and spaces of the uterus. Baths and drinking of salt waters, Fl. ex. 
hydrastis Canadensis mm. xx-xxx should be administered three times 



FUNCTIONAL DISORDERS. 195 

daily in black coffee beginning eight to ten days before the expected 
period. This plan of treatment, regardless of the supposed cause of 
the dysmenorrhea is beneficial. Hydrastis Ext. cotton root ext. viburn. 
prunifoL, stypticin; and ergot have all been found to give relief. Tr. 
gelsemium gtt. was advocated by Pryor. When the physician is sum- 
moned to relieve the intolerable pain morphine subcutaneously affords 
the quickest relief but there is serious danger of forming the habit. 
Cocain is objectionable for the same reason. Antipyrin hypodermically, 
pyramidon, salipyrin, or aspirin internally, are effective for the attack. 
In obstinate cases, dilatation followed by the curet, the Apostoli treatment 
with an intrauterine probe employing from 25 to 50 milliamperes. The 
hard rubber or glass drain will probably prove most serviceable. The 
drain should be inserted after the uterus has been dilated and cureted. 
It is generally advised that it be worn for a month or six weeks, but 
I have found no detriment from a longer retention, and have a patient 
in whose uterus I had to re-insert it when it came out after she had worn 
it for four months. For the most difficult cases and especially the mem- 
branous the establishment of the menopause by the removal of the ovaries 
may be the only certain measure for relief. 

172. Copulation. The harmony of the marriage depends essentially 
on the ability of both parties to the contract to enter satisfactorily into the 
sexual act. For this important act in the preservation of the species and 
the mutual self-respect of the contracting parties no preparatory instruc- 
tion is given. Unfortunately at the present day too frequently the prin- 
cipal aim is to gratify the sexual desire and avoid its legitimate conse- 
quences. The ultimate purpose of the sexual act is the promulgation 
of the species and its provisions cannot be violated without one or both 
parties thereto suffering from it. Over-indulgence and inability to in- 
dulge properly on the part of the male are equally prejudicial to the woman. 
The former, where the woman is unresponsive, means that she is a sexual 
slave who develops a repugnance to her mate and hatred at his approach. 
In the union of a lustful erotic woman to a man advanced in years, in 
whom the fires of youth have become feeble, whose erection is slight and 
ineffective, the marriage relation becomes sexual torment. Some of the 
causes for unhappiness in the marriage relation may be enumerated as 
follows: assumption on the part of the male that his desire must be 
gratified regardless of the inclination or want of inclination on the part 
of his companion — in other words that she has no control over her body 
that he is bound to respect; undue precipitancy on the part of the male 
which leads to the completion of the act before the orgasm occurs in the 
woman which awakens appetite without gratifying it; impotency on the 
part of the man which keeps the woman in a state of expectancy until 
she loses all hope of gratification. 

Obstructions to the completion of the contract on the part of the 
woman may arise from malformations of the genital tract; absent or small 
vagina; firm, resisting hymen, rendering entrance impossible; extreme 
fear and nervousness; or an irritable condition of the vulva and vaginal 
entrance rendering the sexual act an agony. More than is usually ap- 



196 GYNECOLOGY. 

preciated depends on the mutual trust and confidence with which the 
first attempt at the sexual act is undertaken. Inconsiderate or violent 
efforts leave the woman sore and with a sense of outrage. Frequent and 
repeated intercourse while the vulva is sore and injured but adds to the 
agony and distress. Sympathy and consideration on the part of the man at 
this period is laying up a treasure which will remain in the memory of 
the woman during life. Pain during coition is known as dyspareunia. 
This may be transient, as the first intercourse is always painful and 
subsequent sensitiveness will depend on the frequency of the practice. 
Many of the hindrances of the relation are psychic. The fear of being 
unable to accomplish the act properly may render the man partially im- 
potent. One failure causes him undue anxiety regarding future attempts. 
The dread of pain, the mental anxiety thus caused induces a pernicious 
nerve state in the woman. 

173. Vaginismus is an abnormal hyperesthesia of the external 
genital organs which produces muscular spasm. It is common in young, 
nervous, or hysteric women, and occasionally occurs without our being 
able to discover any source of irritation. Generally, a careful examina- 
tion will disclose an irritable spot in the fossa navicularis; an inflamed 
and thickened hymen, which has failed to rupture, or, when it has ruptured, 
irritable carunculae myrtiformes; fissure in the fourchet or around the 
orifice of the vagina; small ulcerations within the hymen; fissure of the 
anus; urethral caruncle or an irritable urethra. Nervous irritation of 
the vulva may be engendered by association with an impotent or partly 
impotent man. 

Symptoms. Dyspareunia, or painful coition, and sterility are the most 
marked symptoms. The slightest touch, or even the approach of the 
male, may cause powerful spasm of the sphincter vaginae muscle. I have 
seen a similar spasm occur at every attempt at urination in a very hyster- 
ical woman. The suffering is so intense as to lead the patient to seek med- 
ical advice at once though through a sense of delicacy she may endure the 
distress until it becomes intolerable. She becomes careworn, anxious, 
and even hysteric. The ordinary vaginal examination is often extremely 
painful. I have, however, observed patients in whom the pain seemed 
confined to the attempts at coition. They apparently experienced no 
unusual discomfort during a careful pelvic investigation. Before attempt- 
ing digital examination it is well to inspect the surfaces carefully when, 
by pushing the labia apart, possibly the cause will be discovered. Hilde- 
brandt has described a form of vaginismus due to spasm of the levator 
ani muscles, known as superior vaginismus, which is responsible for that 
unpleasant complication, penis captivus. It must not be overlooked 
that dyspareunia is occasioned by pathologic lesions of the floor of the 
pelvis, such as prolapsed, inflamed ovaries and tubes, inflammation of 
the cervix, pelvic cellulitis, or peritonitis. 
' Prognosis as to cure is good. 

In Treatment. The first essential must be the removal of the cause. 
When the hymen is thickened and sensitive, it may be necessary to cut 
it completely away. Its mucous surfaces, however, should be sutured, 



FUNCTIONAL DISORDERS. 197 

in order to preclude the formation of cicatricial tissue. In irritable fissure 
the base should be divided, as in fissure of the anus, or touched with the 
thermocautery. Local applications are often effective, of which one of 
the best is iodoform in powder or ointment. Its disagreeable odor, 
which often precludes its use, may be overcome by rubbing a few drops 
of oil of eucalyptus with each ounce of the powder. Pledgets of cotton 
soaked in a 4 per cent, solution of chloral or in a 2 per cent, solution 
of carbolic acid are useful. Ointments of opium, belladonna, or ichthyol 
often afford relief. Neuromata, irritable carunculae myrtiformes, and 
urethral carunculae should be snipped off. In fissure of the neck of the 
bladder the urethra should be overstretched and cocain filaments or 
pencils should be used. In obstinate spasm glass dilators or plugs 
(see Fig. 177) should be worn for an hour night and morning. Pain 
caused by the introduction of the plug soon ceases, and can be decreased 
by anointing it with a medicated ointment. These instruments should 
gradually be increased in size. When the dilator cannot be worn, re- 
course should be had to operation. 

Injuries and lacerations of the hymen should be considered as con- 
traindicating attempts at intercourse until they have healed. 

Sims divided the superficial fibers of the sphincter vaginae — the bulbo- 
cavernosus muscle. With the patient anesthetized, two fingers of the 
left hand are passed into the vagina to stretch the ostium. An incision 
about two inches long is made on each side of the fourchet, extending 
from half an inch above the ostium to the raphe of the perineum. The 
ostium is plugged thoroughly with gauze, which is kept in position 
by a T-bandage. This plugging is important to prevent hemorrhage. 
The gauze is removed the following day, after which the glass plug should 
be worn a portion of each day for several weeks. 

For incision, forcible stretching may be substituted. This is accom- 
plished by introducing the thumbs (Tilt) or several fingers of each hand 
(Hegar) and forcibly separating them until the muscular fibers yield 
under the traction. This procedure affords the advantage that it is 
bloodless and that it leaves no granulating wound to cause a cicatrix. 
The galvanic current has proved beneficial. Constitutional treatment 
always should be combined with the local measures. Quinin, arsenic, 
and strychnin should be given. Outdoor exercise and change of scene 
should be encouraged and complete sexual rest enjoined. 

174. Sterility. The continuation of unguarded intercourse without 
fecundation, or where fecundation occurs without bringing the fruit 
to maturity is denominated sterility. Sterility is called primary when 
no matured ovum has occurred and secondary when the woman remains 
for years unfruitful after one birth. The conditions necessary for fruit- 
ful coition are: i. A healthy ovum with sufficient vitality to become en- 
grafted in a favorable soil and then develop when fecundation has oc- 
curred. 2. Healthy and vigorous spermatozoa capable of making the 
voyage through the uterus and tubal canal to its union with the ovum. 
3. Conditions proper to favor the union or contact of the vitalizing ele- 
ments either in the act of coition or when they are deposited in the 



igS GYNECOLOGY. 

vagina. 4. A healthy soil in which the fecundated seed can take root, 
receive proper nourishment, and, when matured, be cast off in a condition 
to maintain a separate existence. 

1. Nature is unsparing in her provision for the transmission of life. 
Each ovary is supplied with many thousand ova or follicles capable of 
supplying them. That more of these do not become fecundated demon- 
strates that fortunately some defect of development exists which prevents 
their fecundation. Under the most favorable circumstances it is only 
the occasional ovum in which all conditions seem favorable and a fruitful 
coition results. In some individuals the number of ova capable of 
entering into this cooperative movement seem to be very infrequent and 
thus will appear but a single fruitful cohabitation. Such failure is to 
be expected in a woman with absent or defectively developed ovaries; 
or where these organs have been partially destroyed by diseased processes 
subsequent to puberty. The healthy fecundated ovum has a potential 
force which enables it to fasten upon and receive nourishment from 
any favorable soil with which it may come in contact. This favorable 
soil is generally recognized to be a surface lined with cylindrical epi- 
thelium. Thus the germinated ovum finds its most favorable resting 
place in the uterus. Occasionally it has the misfortune to become arrested 
and subsequently develop in the same portion of the tube. It grows 
rarely in the ovary and with the greatest rareness on the peritoneum. 

2. The researches of the physiologists have demonstrated that a 
number of chromosomes are furnished by the female in the ovum and 
an equal number come from the male in the spermatozoid and the union 
of these results in fecundation and the promulgation of vital forces which 
result in a new being. It is evident then that for fruitful coition the 
spermatic fluid of the male must contain well-developed spermatozoids, 
which, when united with the ovum will furnish the necessary vitalizing 
impulse. Failure to secure fruit after prolonged continuation of the 
marital relation then should not be ascribed only to the woman. Care- 
ful investigation of her organs failing to reveal any mechanical cause 
for the failure, repeated microscopical investigations of the recently dis- 
charged semen should be made to make sure that it contains the neces- 
sary spermatozoids of sufficient vigor and vitality to render them effective 
agents. The woman should not be subjected to operative measures 
for sterility, unless palpable conditions otherwise demand it, until the 
suggested investigation of the male fluid has been made. The investiga- 
tions of Kohner, Fabringer, and other have rendered it probable that 
in from one-fourth to one-third the unfruitful cases the man is responsible. 
The attempted cohabitation may be ineffectual from inability to deliver 
the fluid into the vagina as in hypospadias, defective development, or 
from psychic impotency. The mere fact of potentiality, however, should 
not be accepted as evidence of ability to procreate without the microscopic 
investigation, for from the baneful influence of gonorrheal infection, or- 
chitic changes may result so that a condition of aspermatism exists. 
Considering these conditions it will not be far out of the way to ascribe 
one-third to one-half of the unfruitful marriages to the man. Some 



FUNCTIONAL DISORDERS. 1 99 

place this responsibility at 70 per cent. If we add the inability on the 
part of the man to the results of infection he has conveyed to the woman 
this percentage is more than justified. 

3. It was formerly considered that in the act of coition the penis of 
the male was in union with the uterus and the spermatic fluid was practi- 
cally injected into that organ. The orgasm which in the male results in 
the discharge of the spermatic fluid, in the woman squeezes out of the 
cervix a small plug of viscid secretion which, when drawn back, draws with 
it the spermatozoa or affords a favorable material for their progress. This 
alkaline secretion favors their activity while the acid secretion of the 
vagina is inhibitory. An elongated cervix, a small cervical canal free 
of secretion, a retroverted uterus, a deep retrouterine fornix or one so 
shallow that the semen is not retained, a tortuous or obstructed cervical 
canal from acute anteflexion are barriers which assist in rendering fecun- 
dation difficult. Inflammatory changes in the uterus and especially 
the tubes are still more effectual barriers. If complete these may restrict 
the entrance of an ovum so that the possibflity of vitalization is effectually 
prevented. Oophoritis and perioophoritis are also factors in the exclu- 
sion of possibilities of fecundation. Neoplasms, may obstruct some 
portions of the genital tract of the woman. While the deposit within 
the genital organs of the woman of semen possessing vigorous well- 
developed spermatozoa is regarded as essential to conception, it should 
not be overlooked that occasionally a vigorous spermatozoid cast away 
on the inhospitable shores of the vulva may brave the hostile acid secre- 
tions of the vagina and, revived, after reaching the invigorating fluids of 
the uterus, undaunted by the opposition of the cilia, or its absence, in 
portions of the tube, may stem its course through a narrowed and tortu- 
ous canal until it finally reaches its goal — its other half, the ovum. 
With their union fecundation is accomplished. The healthy semen 
contains many of these organisms whfle but one slightly introduced is 
sufficient. 

4. We have seen that the fecundated ovum had the ability to fasten 
itself on a favorable soil, imbed itself, and obtain therefrom the nutrition 
necessary for its existence and growth. Changes in the endometrium 
which render it unfit to receive the ovum by the formation of a decidual 
membrane necessarily prevents its attachment, or later when attachment 
occurs, favors the consequent abortion. Long continued inflammation 
not only produces unfavorable conditions in the endometrium, but results 
in metritis which leads to substitution of fibroids for muscular tissue by 
which the expansive power and consequently the ability to accommodate 
the development of the ovum is limited. Inflammatory alterations of 
the tube may be of such a character that while admitting the entrance of 
the fecundated ovum into the tube, they so limit or obstruct its progress 
that the pregnancy becomes an ectopic one with all its attendant dangers. 

Diagnosis. The recognition of sterility is rendered difficult by in- 
ability to comprehend all the factors which may cause it. An unfruitful 
marriage may result from efforts to prevent conception. These employed 
for a length of time may produce such changes as seem to render the 



200 GYNECOLOGY. 

individual immune to its occurrence. It is not an unusual occurrence 
after years of unfruitful wedlock for women who doubt their ability to bear 
children to become pregnant, and the spell once broken to bear several 
in succession. The diagnosis of sterility seems justified when the couple 
who desire children are unfruitful after three years of wedded life. Absent 
or defective genital organs are rendered evident by the absence of 
menstruation and the physical examination of the patient. Absence of 
menstruation in the presence of good health is a frequent indication of 
want of development or degenerative changes. Failure of menstruation 
for a number of years, however, should not be considered as affording an 
absolutely unfavorable prognosis as the following brief history would 
indicate. Some years since I assisted Prof. Keen of Philadelphia in an 
operation on a woman thirty years of age who had not menstruated for 
eight years and had been married three years without pregnancy. The 
left ovary, the size of a walnut, was removed and the advisability of the 
removal of the other which contained small cysts considered. As they 
were not large I suggested puncturing them with a cautery and retaining 
the ovary. A number of punctures were made and a few months sub- 
sequent to her operation she began to menstruate and shortly there- 
after became pregnant. She subsequently gave birth to three children. 
Sterility as a result of inflammation can be inferred from a history of 
pelvic attack and the recognition by pelvic examination of the fixation 
of the uterus or the appendages. The failure after careful investigation 
to discover any condition which should cause sterility in the woman 
should lead to a careful and repeated investigation of the fresh semen 
from the husband. The woman should not be subjected to an operation 
unless indicated for other causes than the sterility without the careful 
investigation of the husband's possibilities. 

Treatment should consist of regulation of the nutrition, the employ- 
ment of measures to improve the general health, change of scene, sea 
air, sea bathing, and especially a sea voyage, infrequent sexual indul- 
gence. The potentiality of the man and the susceptibility of the woman 
are often favored by sexual rest. Dilatation of the uterus, absorption 
of inflammatory exudates, correction of malpositions are therapeutic 
measures. In susceptibility to abortion — especially where it is the 
result of syphilitic infection potassium iodid is the most effective agent. 
Its influence in overcoming the tendency to habitual abortion is quite 
as effectual in the nonsyphilitic as in the syphilitic disease of the endo- 
metrium. 

MALFORMATIONS. 

175. Definition and Classification. A genital malformation is 
any deviation from the normal form and structure of the reproductive 
organs. As the processes of development are not complete before puberty, 
such deviations may arise from the arrest of growth, or its 
distortion, at any time previous to it. The great majority of abnormal- 
ities are due to prenatal causes and therefore are congenital. 



M.\LFOR:y:\TIOXS. 



2or 



176. Bifidities. The origin of the uterus and vagina in the coal- 
escence of the two Miillerian ducts naturally results in their more or less 
complete separation into two canals when the continuation of the process 
of growth is faulty or arrested. The bifid development may be either 
equal, or unequal; may result in the formation of two canals by a simple 
partition or septum through what appears to be one body; or a partial 
or complete separation in two bodies. 

177. The Degrees of Division. The most frequent malformation 
is a more or less complete septum forming two canals between the uterus 
and vagina. According to its extent, this may consist of five degrees. 
The first degree (I, Fig. 165J will present the mere outline of a partition 
which projects from the fundus. Such a condition rarely is recognized 





Fig. 165. — Degrees of Di\ision of the 
Genital Tract. 



Fig. 166. — Uterus Bi( 



during life, unless opportunity is afi'orded for digital exploration of the 
uterine cavity. In the second degree (II, Fig. 165) a septum extends 
through the body to the internal os. This form can be recognized fol- 
lowing delivery or abortion, but otherwise may give no indication of its 
presence. Such a septum may be destroyed by a pregnancy. In the 
third degree (III, Fig. 165) the body and cerv^ix are divided by the septum 
into two distinct canals. The fourth degree (J\\ Fig. 165) affords a 
septum which is incomplete in the lower half of the vagina, and the 
■fifth degree (V, Fig. 165 and 173) presents a complete uterovaginal 
septum, forming two canals. One of these canals may be overlooked 
readily, or coition may occur in either side, indifferently. 

178. Double Uterus. The division of the uterus into two portions 
may be partial or complete, and consequently forms three classes: 



202 



GYNECOLOGY. 



First, the division of the fundus by a groove and two lobes, known as 
the uterus bilobularis, uterus bicornis arcuatus, or uterus bicornis 
unicollis (Fig. 167), the latter especially when but one cervical canal 
exists. 




Fig. 167. — Uterus Bicornis Unicollis. 




Fig. 168.— Uterus Bifidus. 



Second, the body divided into two distinct portions, the double uterus 
bicornis (Barnes) — uterus bifidus; it may have a single or two cervical 
canals. (Fig. 168.) 



MALFORMATIONS. 



203 



Third, two separate organs exist, each with one tube and ovary, 
uterus didelphys. (Fig. 169.) The bodies diverge, each half being held 
to its corresponding side by the short broad ligament. 

179. Unequal Development of the Two Sides. The two canals 




Fig. i6g. — Uterus Didelphys. 

of Mliller may be incompletely developed and thus produce asymmetric 
organs of varying form. One canal may be completely atrophied, while 
the other presents a well-developed horn^ — the uterus unicornis. (Fig. 
170.) Generally, the absence of one horn is associated with absence of 




Fig. 170. — Uterus Unicornis. 

the corresponding tube and ovary. The horn may be rudimentary or 
partly developed, permitting the occurrence of menstruation and even 
pregnancy. Such a horn generally is not prepared to continue to maintain 
the fecundated ovum to the completion of gestation, and may cause 



204 



GYNECOLOGY. 



rupture prior to the sixth month. Not infrequently the occurrence of 
such a pregnancy is quite as dangerous to life as a tubal gestation, from 
which it cannot always be differentiated prior to operation. I have 
seen a one-horned uterus which had passed successfully through more 
than one pregnancy and the abnormal condition was only discovered by 
accident. Atresia may exist in the canal of a rudimentary or partly 
developed horn and lead to an accumulation of the menstrual secretion 
and the formation of a tumor. (Fig. 171.) Diagnosis is extremely diffi- 
cult and may be determined 
only by operative procedure. 
The accumulation may rup- 
ture into the vagina, but 
usually at such a height as to 
leave a portion of the sac 
dependent and undrained, 
likely, therefore, to become 
infected and cause septicemia. 
When recognized, treatment 
should be that for retained 
menstruation, to be described 
later. The development of a 
one-horned uterus may be as- 
sociated with a double cervical 
canal — uterus hiforis — a con- 
dition which may cause em- 
barrassment during labor. 
The septum when discovered 
may be pushed to one side, 
or, if necessary, be cut be- 
tween two sutures (Pozzi). 
When torn, it has caused 
severe hemorrhage. 

180. Absent Uterus. Entire absence of the uterus is rare, and 
almost always is associated with absence of the other genital organs, 
particularly the vagina. The determination of the condition is difficult. 

The introduction of the index-finger of one hand into the rectum 
and that of the other, or of a catheter into the bladder enables the 
operator to explore the pelvis thoroughly. Failure to recognize the 
organ may be due to its rudimentary condition or its displacement to 
one side, and we can assert its entire absence only when we have been 
able to explore the pelvis through an abdominal incision or during an 
autopsy. 

181. A rudimentary uterus may exist in the form of a slight thick- 
ening over the surface of the bladder, as two undeveloped canals in the 
form of a T — the uterus hipartitus. (Fig. 172.) The vagina is frequently 
absent or may be partly developed, deepened by coition, or may exist 
as a small culdesac continuous with the urethra, which has been dilated 
by repeated efforts at coition. Menstruation is generally absent; ovula- 




FiG. 171. — Atresia of Rudimentary Horn with an 
Accumulation of Menstrual Blood. 



MALFORMATIONS. 



205 



tion may occur without molimina, or there may be the occurrence of 
hematometra. 

When the vagina is well developed and menstruation occurs, the 
condition may remain undiscovered. The rudimentary character of the 
organ can be determined by bimanual palpation or by palpation through 
the rectum and the bladder, as has been described. The occurrence of 
painful molimina may require castration. 

182. In fetal and infantile uteri from arrest during the fifth stage 
of development the uterus is small, the cervix two or three times the length 
of the bodv, and an acute anteflexion of the body probably exists. 




Fig. 172 — Uterus Bipartitus or Duplex. 



Fig. 173, — Uterus Biseptus. 



The infantile uterus differs from the fetal "in the arbor vitae arrange- 
ment of the mucous membrane which no longer extends to the fundus. 
Menstruation rarely occurs, and sexual desire is generally absent. The 
external genitals may be poorly or well developed. The breasts not 
infrequently are normal. 

183. Treatment of Uterine Malformations. A malformed uterus 
is one imperfectly developed, in which the functions must be performed 
feebly. A septum through the uterus and vagina may cause dyspareunia 
by the diminished size of the vagina. It need not produce distress nor 
danger during gestation, but not infrequently the cervical and vaginal 
septa are a cause of dystocia. 

A vaginal septum should be cut through its entire length and the 
edges of each wall sutured to prevent readhesion. Its division by the 
thermocautery has been advocated to save the time given to suturing. 
The cervical septum can be crushed by forceps, which should be left in 



2o6 GYNECOLOGY. 

place to produce necrosis of the compressed tissues. These septa do not 
generally survive the first gestation, but are broken down during the 
labor. I have several times seen a bridle of tissue attached to the lower 
portions of the anterior and posterior vaginal walls, which were, without 
doubt, remnants of an originally more complete septum. 

The division of the uterus into two equally developed portions does not 
usually call for treatment as pregnancy has frequently occurred with- 
out appearing to produce difficulty in parturition. 

A patient upon whom hysterectomy was done for interstitial myomata 
had previously given birth to two children, apparently without any un- 
usual phenomena. The operation disclosed upon one side a rudimentary 
horn which had its cervical canal, opened into a blind pouch for a vagina, 
and was situated between the existing vagina and the bladder. 

The adjoining cornua of a partially bifid uterus may be split and 
trimmed and their edges sutured to form one cavity. It may be questioned 
how such a reconstructed organ will endure the course of a gestation, 
but if pregnancy can go to full term in one horn of a uterus such an 
organ should be more capable of performing its physiologic functions. 
Where the uterine cornua are unequally developed, there is danger from 
conception in the rudimentary cornu. The recognition of the existence 
of such a pregnancy should be considered ample justification for its 
extirpation. Where both cornua are rudimentary and the patient suffers 
from menstrual molimina, the abdomen should be opened and the ovaries 
removed. Similar procedure is proper when the uterus is absent. 

Fetal and infantile uteri frequently present conditions in which the 
function of menstruation is performed irregularly and attended with 
severe pain. The probability of the patient becoming pregnant and 
carrying the fetus to full term is dependent upon the degree of develop- 
ment. Under the stimulation of the marital relation such uteri occasion- 
ally increase in size. More frequently the individual complains of 
irregular and painful menstruation and is sterile. 

184. Absent or Rudimentary Tubes. Absence of the Fallopian 
tubes is rare, and occurs with a similar absence of the ovaries and uterus. 
One tube is more frequently absent and a unicornate uterus accompanies 
it. A rudimentary tube results generally from an attack of fetal periton- 
itis. The tube may be a simple cord and yet have fully developed fimbria. 

The fimbria may be independent of the openings. Additional ostia are 
frequent. Ferraresi found six openings upon one tube, all of which 
were surrounded by fimbria. While generally at the end, these openings 
may occur in the middle of the duct, and are probably due to failure in 
clocure of the groove in the germinal epithelium or to splitting of the 
Miillerian duct after it has closed. 

The normal tube is 10 to 12 cm. long; in ovarian or broad liga- 
ment cysts and in ovarian hernia a tube may be 16 to 18 cm. long. 

185. Absence of ovaries is exceedingly rare. The abdominal 
cavity must be inspected to confirm the suspicion. Absence of one is 
less rare, is associated with a unicornate uterus, and occasionally with 
absence of the corresponding kidney. The rudimentary ovary is more 



MALFORMATIONS. 



207 



frequent and may be fetal or adult. It may contain no glandular tissue, 
or the presence of unclosed Pfliiger's tubes may indicate the existence of 
a testicle. The condition may be produced by oophoritis or peritonitis 
during fetal or adult life, or by the twisting of a pedicle. 

186. Extra ovaries are very rare. Von Winckel found a third 
ovary in front of the uterus. Tufts of ovarian stroma have been 
described. The occurrence of menstruation — even pregnancy — after the 
supposed removal of both ovaries has been reported, but it is more 
probable that in all such cases 

there was failure to remove 
the entire structure of both 
glands. 

187. Accessory or con- 
stricted ovaries are more 
frequent. A portion of the 
ovary may hang from the 
main body by a more or less 
well-marked pedicle. Two or 
three have been found asso- 
ciated with one ovary. 

The ovary may descend 
and be situated at, or below, 
the brim of the pelvis. An 
ovary in a hernial sac is often 
difficult to recognize, and pro- 
ductive of serious distress. 

188. Round and Broad 
Ligaments. Absence of the 
round ligament is generally 
associated with defects of the 
uterus. The muscular struc- 
ture of the round ligament 
was completely absent in one 
of my patients. The broad 
ligament fold in which the 
round ligament would lie was 
a thin corrugated margin. Fig. 174.— Absent Vagina. 
The persistence of the canal of 

Nuck permits the formation of a hydrocele, which may become quite 
large in the labia majora. The broad ligaments may be absent, ex- 
tremely short, or unequal in length and thickness. They often contain 
cysts which are relics of the parovarium. 

189. Absent or Rudimentary Vagina. \\Tien the vagina is absent, 
no trace of its tissue will be found between the rectum and bladder. 
These two organs are separated by connective tissue only. (Fig. 174.) 
The rudimentary vagina may exist as a fibrous cord, indicating the site 
of the ducts of Miiller, whose development has been arrested early in 
fetal life. One of the segments of the vaginal canal may be absent with 




2o8 



GYNECOLOGY, 



an incomplete development of the other. The uterus, also, may be absent; 
reduced to a rudimentary nodule; or more or less defective in its develop- 
ment. Rarely is a well developed uterus found in absence of the vagina. 
Normal ovaries are scarcely ever present without manifestation of men- 
strual molimina although the only manifestation may be periodic pains dur- 
ing ovulation. Vicarious hemorrhage from different portions of the body 
with extreme pains have been reported as occurring at the supposed 
menstrual periods when a well formed uterus existed. While the vulva 

also may be absent, it is more fre- 
quently well formed, presenting a 
funnel-shaped depression behind well 
developed nymphae. The hymen may 
be perfectly normal, while the urethra 
is at times dilated by the efforts made 
at coition. It is difficult to determine 
why the lower portion of the vagina 
should be present most frequently in 
cases of arrest in development. It is 
probably because of an abnormal 
elongation of the vestibular canal. 
This pouch, in the absence of the 
vagina and uterus has been found 2 
or 3 cm. in length and sufficiently 
wide to admit the finger. These 
dimensions are considerably increased 
by sexual efforts. The opening is 
generally closed by a pearly reticu- 
lated membrane, apparently cicatri- 
cial. The central portion of the 
vagina may be absent, or replaced by 
a membrance of variable thickness 
which is at times perforated. I saw 
one patient in whom the upper and 
lower halves of the vagina were divided 
by a membrane which had a small 
opening at one side through which the 
menstrual discharge escaped. This membrane was incised and a good 
sized cavity was opened. A serviceable vagina was formed by removing 
a section of the septum and suturing the raw surfaces. When the vagina 
is absent, the condition should be determined by a finger in the rectum and 
a catheter or a sound in the bladder. Combined rectal and vesical touch 
permits the recognition of the uterus and its degree of development. 

Treatment. When the vagina is wholly or partially absent, different 
methods of treatment are demanded according to the development of the 
uterus. If the latter is normal and symptoms of menstrual molimina 
have occurred, or if the uterus has increased in size, hematometra should 
be suspected and interference is indicated. Absent uterus with well 
developed ovaries causing recurring pain requires castration. Absent 




Fig. 175. — Line of Incision for Forma- 
tion of Flaps. 
I, 2, 3. Flaps from labia minora which are 
split and used to Une the vagina. 



MALFORMATIONS. 



209 



vagina makes the woman sexually incompetent and brings up the question 
whether a vagina shall be constructed for sexual purposes. Amussat 
first performed the operation to construct a vagina. An incision is made 
through the vulvar surface separating the bladder from the rectum by 
blunt dissection until a depth of 6 to 8 cm. has been reached or the peri- 
toneum opened. The second steps of the operation consist in the in- 
vestment of the opening with integument to prevent cicatricial contraction. 
The adjacent skin and mucous 
membrane may be employed. 
When the labia minora exist 
they can be split and utilized 
for lining the anterior portion 
of the canal, while flaps can 
be taken from the vulva and 
inner side of the thighs to 
cover the posterior wall. 
(Figs. 175 and 176.) After 
the flaps are secured by 
sutures the cavity is packed 
with iodoform gauze which is 
retained, or renewed, until 
cicatrization is complete, after 
which the canal can be kept 
open by a glass plug. The 
opening has been maintained 
by the glass plug (Fig. 177) 
without lining the canal. Be- 
cause of the cicatricial con- 
traction, however, it is exceed- 
ingly difficult to keep such a 
canal open, even though an 
obturator be constantly worn. 
The lining of such a canal has 
been secured by utilizing the 
redundant vagina from an- 
other patient. The tissue 
should be sutured over a glass 
plug (Fig. 177), or, preferably, 
over the end of a slightly dis- 
tended bivalve speculum, after which it is introduced into the canal, 
and, as the speculum is withdrawn, the cavity packed lightly with iodo- 
form gauze. While awaiting the preparation of the vaginal lining the 
cavity should be packed with gauze temporarily, and the packing intro- 
duced within the hood should be removed at the end of a week. If the 
tissues have united by this time, it should be irrigated, removing any 
tissue that has not retained its vitality. 

In the patient represented by Figs. 175 and 176, after forming the wall 
of the anterior portion by splitting the labia minora, a flap was trans- 
14 




Fig. 176.— Flaps outlined in Fig. 175 Sutured in 
Place, and Denuded Surfaces which Have 
Furnished Flaps to line Posterior wall. 




2IO GYNECOLOGY. 

planted from the posterior part of each thigh. Fortunately this became 
attached and a satisfactory vagina was formed. 

In making the dissection for the vagina, the operator should not hesitate 
to open through the peritoneum. Such an opening permits the presence 
and size of a rudimentary uterus to be determined more readily, and the 
cervix affords a safe point for the fixation of flaps to line the constructed 
vagina. I do not doubt that the employment of a portion of the sigmoid 

or ileum, as advocated by Bald- 
win, of Ohio, will prove the most 
efficient vagina. Such a pro- 
cedure necessarily requires an 
abdominal incision, as the cul- 
desac of the bowel must be 
restored by anastomosis throw- 
FiG. 177.— Sims' Glass Dilator. ing out the loop Utilized for the 

vagina. 

190. Double Vagina. The septum may divide the entire vagina. 
(Fig. 178.) The uterus, also, will be double or divided. Occasionally, 
the septum in the uterus does not extend through the external os, while 
that of the vagina terminates below it. The hymen may have two open- 
ings, simulating double vagina. Coition generally occurs through the 
larger of the two conduits; occasionally it may occur in either one. When 
the vaginal partition is partial, the upper portion of the septum will be lack- 
ing. When the uterus is double, the upper portion of the vagina often is 
found to contain the septum, while fusion has been complete below. The 
septum is usually thick and fleshy, resembling the rectovaginal partition, 
or it may be very thin, and even perforated in places. Partition of the 
vagina is not incompatible with normal labor. Dunning has reported 
cases in which the two vaginae were separated by a septum that began 
just above the vulva and extended to the interval between the two small 
cervices. The separation of the uterus into two parts was demonstrated 
by the use of the sound. Pregnancy occurred upon the right side and, 
as the uterus enlarged, the septum disappeared. During labor the vaginal 
portion was torn from top to bottom and only the lower portion persisted. 
An incomplete septum may form an obstacle to the passage of the child's 
head. When it does so, it should be incised. I have seen several pa- 
tients who had a vaginal septum destroyed in labor previously, and there 
remained a bridle extending from the anterior wall of the vagina back 
to its posterior commissure, which hung below the vulva. Twice have 
I cut through a septum the entire length of the vagina and sutured the 
surfaces on each wall, so that a single canal was formed. This course 
I considered wise as it decreases the discomfort during coition and removes 
a cause of dystocia in the event of pregnancy. 

Arrest of development in one of the ducts results in a unilateral 
vagina. It is not uncommon in double vagina to find incomplete de- 
velopment in one of the ducts. 

191. Atresia of the genital canal is either congenital or acquired. 
The latter will be discussed later. Congenital atresia may affect any 



MALFORMATIONS. 



211 



portion of the canal, but is more likely to occur within the vagina or near 
its orifice at the junction of the vagina and vestibular canal. Next in 
frequency is the atresia of the internal or external orifices of the cervical 
canal, although the congenital closure of these orifices is comparatively 
not nearly so frequent as the acquired. Vulvar atresia is not uncommon. 
It is produced by imperforation of the hymen or agglutination of the labia 
minora or majora. In the latter there is usually an orifice in front through 
which the urine and menstrual flow can escape. Such conditions are 
often unrecognized until after the establishment of puberty, when the 




Fig. 178. — Double Vagina. {Photograph taken from patient of Dr. J. M. Fisher.) 



occurrence of periodic distress in the pelvis, colic-like pains, sensation 
of weakness, bearing down, and irritability of temper indicate an effort 
to establish the menstrual flow. The continuance without discharge 
and later the development of a tumor in the median line should awaken 
the suspicion of the attendant to the possibility of obstruction to the 
menstrual discharge and of its accumulation within the genital canal. 
The mere inspection of the parts discloses the imperforation of the hymen. 
(Fig. 179.) A tumor will protrude from the vulva; there is difficulty 
or abnormal frequency in micturition, more or less obstruction in evacu- 



212 



GYNECOLOGY. 



ating the bowels is experienced, and a smooth, purplish surface is seen at 
the vulvar orifice. If the obstruction is situated in the vaginal canal, 
the vulvar protrusion will not be so marked. The introduction of the 
finger into the canal, however, discloses the accumulation. It is more 
definitely determined by the finger in the rectum, when the globular 
tumor encroaching upon that organ is recognized. Pressure over the 
abdomen causes a sensation of elasticity or indistinct fluctuation. When 
the vagina is absent, the accumulation forms in the upper part of the 
vaginal canal or within the uterine cavity. An accumulation in the 
vagina is known as a hematocolpos in the uterus, as a hematometra; 

in the Fallopian tube, as a hematosal- 
pinx; in both uterus and vagina, as a 
hematocolpometra; and when the disten- 
tion also involves the tube, it becomes a 
hematocolpometrasalpinx. 

The symptoms are absent menstrua- 
tion, although the patient experiences 
each month discomfort, a sense of ful- 
ness or engorgement in the pelvis, with 
the usual nervous manifestations which 
awaken the anticipation that menstrua- 
tion is about to make its appearance. 
A symmetrical enlargement of the lower 
abdomen appears, which from its con- 
tour has been mistaken by the careless 
observer for pregnancy. The history of 
the case, with a careful physical exam- 
ination of the patient, should establish 
the diagnosis. When the obstruction 
occurs at the internal os with a normal 
cervix and roomy vagina, the diagnosis 
becomes more difficult. The mere fact 
that a girl has never menstruated does 
not exclude the possibility of pregnancy. 
In the latter will be found mammary changes, an enlarged and softened 
cervix, increased vaginal secretion, swelling, and a dusky appearance 
of the vagina and vulva. In the accumulation of blood these symptoms 
are absent and the cervix remains small, rather firm, and hard. As 
the accumulation increases the cervix becomes softened, and the uterus 
thinner, forming a thin-walled sac which affords distinct fluctuation. 

Treatment. Operators were formerly very much averse to evacuating 
the fluid of such a collection. The fluid is thick, chocolate colored, and 
quite slimy, due, of course, to the retention of the blood and mucous 
secretions of the canal. It formerly was advised that a small pinhole 
orifice should be made through the opening in the hymen, to allow the 
discharge to continue slowly for several days. Such a procedure resulted 
in infection and produced an inflammatory condition of the genital 
canal which not infrequently caused the death of the patient. The 




Fig. 179. — Imperforate Hymen. 



MALF ORMATI OXS . 



213 



enormous distention of the tissues renders them extremely anemic, and 
the removal of the pressure permits an engorgment, which can readily 
result in inflammation. The most satisfactory method of treatment 




Fig. 180. — Hematocolpos. 




Fig. 181. — Hematometra. 



consists in a free incision to evacuate the contents of the cavity; removal 
of the stringy mucus with the finger, and then thorough irrigation with a 
weak antiseptic solution, such as a two per cent, sodium bicarbonate, 
three per cent, sodium chlorid, bichlorid of mercury (i :4ooo), or formalin 



214 



GYNECOLOGY. 



(1:1500). A large quantity of the solution should be employed; the 
irrigation to be followed, when of the two latter solutions, by a douche 
of normal salt solution. Finally, when the quantity of fluid evacuated is 
large, the cavity should be lightly packed with iodoform gauze to afford 
moderate pressure upon the surface, to prevent engorgement, and to 
give the structures something upon which to contract. When the 
accumulation occurs above an obliterated or absent vagina, a trocar can 
be employed to reach the fluid, guided through the intervening structures 
with a finger in the rectum. The opening made by the trocar is then en- 
larged to permit a free evacuation, and the treatment already advised 
should be employed. When the accumulation occurs in the uterus from 
obliteration of the external os, often it will be difficult to determine the site 




Fig. 182.— Hematocolpometra. 

of the latter. The cervix should be exposed, and if we cannot determine 
the situation of the former os, a puncture should be made with the trocar. 
This opening should be enlarged subsequently in order to permit the 
evacuation of the uterine contents. The cavity is then irrigated and 
packed with gauze. If the obliteration has developed at the internal 
OS, the remaining cervical canal affords a passage through which the 
puncture can be made safely. The canal having been dilated and the 
cavity thoroughly irrigated, the latter should be lightly packed with gauze. 
In all cases in which the obstruction is found in the uterine or cervical 
wall, measures should be instituted to secure subsequently a patulous 
canal, otherwise the obstruction will be reproduced. The better plan of 
procedure will be to suture the internal and external surfaces of the uterine 
opening. 

: The one element of danger in these operations occurs when the Fallo- 
pian tube is distended with an accumulation and is fixed by extensive . 
adhesions. ; /The dragging upon the thin tube which follows the contrac- 



MALFORMATIONS. 215 

tion of the empty uterus may cause its rupture and the escape of its con- 
tents into the peritoneal cavity. Extreme care should be exercised in 
a hematosalpinx not to make much pressure upon the abdominal surface 
while the sac is being emptied. Whenever the sac has disappeared with 
insufficient discharge from the uterus, or when it has disappeared before 
the opening into the collection has occurred, an immediate abdominal 
incision should be made to cleanse the peritoneum and remove the offend- 
ing sac. 

Where the organs are divided by a septum, atresia may take place 
in one-half of a divided vagina or uterus. A lateral tumor will project 
into the vaginal canal, which will be so elastic and obscure as to render 
doubtful the fact whether it is a pelvic cyst or a lateral hematocolpos. 
Such cases are less dangerous than atresia of the entire vagina, as the 
accumulation will probably rupture into, and discharge through, the 
existing vagina. The opening, however, will be high, permitting serious 
symptoms from infection and the development of a pyocolpos. It is 
generally advised to make a free incision and pack such a cavity with 
iodoform gauze, but I much prefer to excise a large section of the wall 
and unite the mucous surfaces of its cut edges so that the two chambers 
become one. When the atresia has occurred in one half of the uterus, 
the diagnosis is difficult. It is not always situated to one side of the 
developed horn, but may curve about it. The accumulation may then 
be accessible through the vagina, or may be exceedingly difficult to reach. 
When accessible it should be opened through the vagina. When inaccessi- 
ble below, the tumor should be removed by an abdominal incision, as 
for pyosalpinx. 

192. Defects of the vulva are generally associated with a similar 
condition of the vagina and uterus, although such a defect may exist 
with a normal development of the other genital organs. It then probably 
results from coalescence of the labia majora. The latter are generally 
absent in exstrophy of the bladder, and may also be found so in other 
malformations. The nymphae can be absent and the clitoris so imper- 
fectly developed that the site of the vulva presents a mere slit or flattened 
surface, upon which the urethral orifice opens. 

Infantile vulva occurs in weak, sickly women, who have suffered 
from prolonged ill health prior to puberty, and is generally associated 
with an imperfect development of the uterus and tubes. The mons vene- 
eris and labia majora will be bereft of, or sparsely covered with, hair. 

193. Defects in Nymphae. Absence of nymphae is infrequent, 
and is accompanied by incomplete development of the clitoris. More 
frequently they are thin, flabby, elongated, and pointed. Occasionally 
they are perforated by small openings. Hypertrophy of the nymphae is 
much more frequent. The nymphae project beyond the labia majora; 
in the bushwomen of Africa they form large folds, which reach nearly to 
the knees, and are known as the Hottentot apron. 

194. Defects of the Clitoris. The clitoris may be so enormously 
developed as to cause the sex of the individual to be questioned. In 
exstrophy of the bladder and absence of the symphysis it may be bifid 



2l6 



GYNECOLOGY. 




or rudimentary. It is rarely absent. Frequently, from congenital con- 
ditions or from neglect of cleanliness, the smegma is retained beneath 
the prepuce, producing such irritation and adhesions that the glans 
clitoris is compressed and prevented from attaining its normal size. The 
adhesions become so firm as to render their separation difficult. The 
existence of adhesions and the retention of smegma are capable of pro- 
ducing quite as marked nervous phenomena as the analogous condition 
in the male, some of which are irritable bladder, nervous disturbances, 

masturbation, absence of sen- 
' j sation, and convulsions. The 

occurrence of such symptoms 
should direct attention to the 
clitoris as a possible cause. 

Treatment. When the 
clitoris is so large as to inter- 
fere with coition, a portion of 
it may have to be removed, 
but the operative procedure 
should, if possible, be so de- 
signed as to retain the glans 
as the seat of sensation. If 
the glans is covered by an 
adherent prepuce, it should 
be thoroughly exposed by 
pushing back the prepuce. 
The adhesions can readily be 
broken up with a probe or a 
grooved director. When the 
prepuce is so long as to form 
a hood and completely en- 
velop the glans, it should be 
retracted by removing an 
elliptic piece of integument 
about half an inch above the 
clitoris, with the long diam- 
eter of the ellipse parallel to 
the cleft of the vulva. This 
denuded portion should be 
closed by sutures introduced in its long axis. The length of the denuda- 
tion necessary depends upon the projection of the prepuce. The prepuce 
may be dissected away and the cut edges sutured so that the glans sub- 
sequently remains exposed. A better procedure is to remove the margin 
of the prepuce around the glans, practically doing a circumcision, after 
which the cut edges should be united with catgut sutures. 

195. Defects of the Hymen. The hymen is composed of tissue 
analogous to the corpus spongiosum in the male. It partly closes the 
vaginal orifice, and has upon its superior surface the foldings of the mucous 
surface of the vagina. It is generally crescentic (Fig. 8), with the con- 





FiG. 183. Enlarged Clitoris. 



MALFORMATIONS. 217 

cave margin anterior. It can present an annular opening (Fig. 8) ; two 
openings, separated by a septum (Fig. 12); or a number of openings 
(Fig. 13) — the cribriform. It sometimes resembles in appearance the 
infantile form, when it is infundibuliform (Fig. 11), or its edges may be 
dentated (Fig. lo) or serrated. Its normal situation is just within the 
vulva, where it is exposed by separation of the labia. In the colored race 
its situation is higher. Its opening in the marriageable woman will easily 
admit the tip of the finger. Atresia has been described. (Section 191.) 
Supernumerary hymen have been reported, but these are probably con- 
genital bridles in the vagina. Cojigenital absence of the hymen must 
be questioned. The hymen is generally a thin membrane, which rup- 
tures during the first coition (Fig. 14) and sloughs away after confine- 
ment, leaving as remnants the carunculae mwtiformes. The laceration 
may be central, posterior, triangular, or stellate. After a single coition 
the torn surfaces may unite. I have seen two patients in whom the 
hymen was so firm as to form an actual barrier to coition, requiring 
incision to render the act possible. Cases are reported where it did not 
rupture during labor, or offered such an obstacle to delivery as to require 
incision. Its laceration is not usually attended with bleeding, but occa- 
sionally it is followed by severe, and even dangerous, hemorrhage. 

Incision is made with bistoury or scissors, while the labia are widely 
separated. Two posterior lateral incisions are preferable to a single 
posterior. Hemorrhage, if severe, should be controlled by a vaginal 
tampon, or, preferably, by a suture. 




Fig. 184. — Apparent Hermaphroditism. {American Journal of Obstetrics.) 



196. Hermaphroditism is a condition in which there is a real or 
apparent union of the two sexes in the same individual. It is doubtful 
whether the organs of both sexes exist complete in any one individual, 
although there are numerous instances in which the penis has been found 
well developed, with a testicle upon one side, while within were found a 
uterus and an ovary upon the other side of the body. The case repre- 
sented in figure 184 presents characteristics of the two sexes, but, like 



2i; 



GYNECOLOGY. 



many other such cases, requires a microscopic examination to demonstrate 
the presence of both ovaries and testicles in the same individual. 




Fig. 185. — External Genital Organs of Madam Le Fort. (Auvard.) 




Fig. 186. — Outline of Internal Organs of Madame Le Fort. {Auvard.) 

Pseudohermaphroditism is a condition in which there is such an appar- 
ent union of the sexual organs of the two sexes, or such a malformation, 
or defective development of the male organs or excessive development 



MALFORMATIONS. 



219 



of those of the female, as to render the determination of the sex of the 
individual during life difficult, if not almost impossible. Pseudoher- 
maphroditism is divided into masculine and feminine, according to the 
presence of testicles or ovaries. The females resembling men form a class 
known as the gynandria, while the man resembling the female is classed 
as an androgynus. 

Gynandria. The external organs of the female resemble those of 
the male. The clitoris is large, with possible fusion of the labia majora, 
not infrequently of the labia minora, simulating the scrotum and con- 
cealing the vulvar opening. This resemblance is still more striking when 
there is associated an ovarian hernia into the labium majus. The internal 
organs may be irregularly developed. The hypertrophy of the clitoris 
does not necessarily change its form, and may arise in women who are 
addicted to masturbation. The labial fusion may be so firm as to 
require incision. 

An example of this class is Madeline Le Fort (Auvard) (Fig. 185), 
who was declared to be a female by Beclard when she was six years of 
age. The clitoris was very large; a groove upon 
the under surface led to a depressed urethra in the 
cleft of the vulva. The vagina was replaced by a 
small conduit, from eight to 10 centimeters long, 
bordering upon a well-formed uterus. (Fig. 186). 
Menstruation occurred at the eighth year, and 
escaped from an orifice situated at the root of the 
clitoris. Her general appearance was strongly 
masculine, and she was sexually indifferent. 

Androgyfia predominates, and its individuals 
are frequently monorchid or cryptorchid males, 
presenting external characteristics of the female, 
such as enlarged breasts. The penis may be perfect, 
but the nondescent of the testicles and a median 
depression in the scrotum resembling the labia 
majora will give a distinctly feminine aspect. 
Arrested development of the penis, hypospadias, 
and fissure of the scrotum greatly increase the 
resemblance. (Fig. 187.) Such persons are gen- 
erally dressed, reared, and educated as girls, and 
have been married without being aware of their true sex. 

The determination of sex is of great importance. It requires careful 
consideration of the size, shape, and general configuration of the body. 
The testicle may be small, and be retained within the abdominal cavity. 
The seminal secretion is generally sterile. The breasts resemble the 
feminine, as do also the buttocks and thighs. The larynx is not prominent 
and the beard is scanty or absent. The rectal touch, with the catheter 
in the bladder, may fail to reveal either uterus or prostate. The mental 
condition is generally feeble or poorly balanced. When careful exam- 
ination fails to render the sex certain, the individual should be classed as 
a male. Independent of increased freedom and larger opportunities 




Fig. 187. — Androgvna. 
(Pozzi.) 



220 



GYNECOLOGY. 



for acquiring a livelihood, the imperfect male is less likely to enter upon 
the marriage relation. When the sex of the individual is in doubt no 
operation for correction of the condition should be done, unless preceded 
by an abdominal section to ascertain the character of the internal genital 
organs. 

197. Hypospadias is much more rare in the female than in the male. 
The vestibule is absent and the orifice of the urethra is not visible to 
inspection. Generally, the apparent hypospadias is really a persistence 
of the urogenital sinus. The urethra can be wholly absent, and the blad- 
der may present a crescentic opening into the vagina. It is often asso- 
ciated with prolapse of the bladder-wall, and incontinence is usually 
present. 

198. Epispadias is still more rare. It presents four varieties: (i) 
The corpus spongiosum is divided, and the urinary sinus is situated in 
the posterior surface of the clitoris; (2) added to the former condition 




Fig. 188. — Imperforate Anus. Communication between Rectum and Vagina. 

there is a partial defect of the anterior urethral wall; (3) the anterior 
wall of the urethra is entirely absent, the clitoris is bifid, and the labium 
minus is attached on either side to a portion of the glans clitoris, while 
the pubic symphysis may also be defective; (4) exstrophy of the bladder, 
in which the anterior wall of the abdomen, with that of the bkdder, is 
absent and the posterior vesical wall protrudes. The ureters open upon 
the surface, and the parts are constantly soiled with urine. 

The first form of epispadias is very rare, the last most frequent. 
While vesical ectopia is prone to result in disease and obstruction of the 
ureters, which lead to hydronephrosis and early death, nevertheless 
histories of patients have been reported who have reached old age. The 
occurrence of epispadias and associated incontinence is not inimical 
to the occurrence of conception, and cases of pregnancy at full term are 
recorded. 



MALFORMATIONS. 



221 



Treatment. The urethra may be established by denuding and 
suturing the surfaces, but failure to secure a good result is frequent. 
Ectopia of the bladder is difficult of correction. It is preferable not 
to attempt an operation during infancy, owing to the friability of the 




Fig. 189. — Congenital Defect of \'agina. Communication with the Rectum. 

tissues and the probability of sutures cutting through. Transplantation 
of the* ureters into the rectum probably affords the most satisfactory 
solution of the problem. 

Duplication of the bladder has been found associated with a similar 
condition of the genitalia. 




Fig. 190. — Congenital Absence of the Urethra. Communication of Bladder with the 

Vagina. 

Permeability of the urachus and discharge of urine from the umbilicus 
are results of congenital closure of the urethra, but sometimes occur in- 
dependently. It is much more frequent in boys than in girls. 

199. Irregular Exit of Ureter. Opening of the ureter into the 



222 



GYNECOLOGY. 



vagina has been described, but these are probably cases in which the 
supposed vagina is really a rudimentary bladder. I had an opportunity 
to examine a young woman in whom the bladder was rudimentary and 
the vagina formed a receptacle in which urine accumulated and prevented 
incontinence becoming complete. Baum describes an accessory ureter 




Fig. 191. — Communication of Rectum and Bladder with the Vagina. 

which opened at the side of the urethra. He operated by making an 
incision above the symphysis, cutting through the bladder upon the 
ureter, which he divided, tying the distal end, while the other was brought 
into the bladder. The procedure overcame the incontinence. 

200. Abnormal Communications. Errors in development may 



% 


1^1 


^a*^#s' ' 'J 






M\ 



Fig. ,192. — Suprapubic Opening of Vagina and Urethra. 

produce imperforation of one of the canals which perforate the pelvic 
fascia or result in the union of two or three of them. In any case the 
cause is analogous: i. e., failure to accomplish the union between the 
superficial and deep organs. Imperforations of the anus and urethra 
are vital, calling for prompt attention of the surgeon. Imperforation of 



TRAUMATISMS. 223 

the vagina has been considered. (Section i88). The communications 
may be : 

1. Rectovaginal. (Fig. i88.) The vagina and urethra are normally 
developed. The anus is imperforate and, therefore, the fecal material 
is discharged by a rectovaginal opening through the vagina. 

2. Vaginorectal. (Fig. 189.) The rectum and urethra are nor- 
mally developed, excepting the opening into the former from the incom- 
plete vagina. 

3. Vesicovaginal. (Fig. 190.) The rectum and vagina are normal 
in appearance, but the urine escapes through the latter, the urethra being 
absent. 

4. Rectovagino vesical. (Fig. 191.) The rectum and bladder both 
communicate with the vagina. The urethra is generally absent. The 
anus may or may not be perforate. 

5. Suprapubic opening of vagina and urethra. (Fig. 192.) This 
condition is extremely rare. 

TRAUMATISMS. 

201. Injuries of the genital organs of sufficient gravity to produce 
temporary or permanent structural changes, or to influence the subsequent 
health and comfort of the patient, for the most part are limited to lesions 
of the vulva, vagina, and cervix. 

The causes productive of such conditions usually may be assigned to 
one of three general classes, viz. : 

1. External violence. 

2. Coition. 

3. Parturition. 

202. External violence as a cause of injury is comparatively in- 
frequent. 

The injuries occur in a variety of ways. 

A woman standing upon a chair or step-ladder falls astride the back, 
or upon the post or round of the chair. 

Bovee reports a young girl who fell from her bicycle upon the lamp 
bracket and sustained a complete laceration of the perineum. Lacera- 
tions may be produced by sliding down bannisters and striking against 
the newel post, by sliding from a haystack or haymow, falling upon the 
handle or prong of a fork or upon a hay-knife. Howe mentions a young 
woman who slid upon the handle of a fork, which entered the vagina 
and penetrated the abdominal cavity twenty-two inches. She ultimately 
recovered. Curran cites the case of a patient in whom the horn of a goat 
entered the anus and tore through the vagina. Girls have been impaled 
upon barrel staves, fence palings, or the sharp stump of a sapling. A 
chamber or slop-jar breaking under the patient has been the cause of 
injury. The fracture of a glass-ball pessary in the efforts at its removal 
has produced vaginal laceration and even fistula. Royster reports two 
cases of complete laceration of the perineum in young girls, which were 
caused by the finger of the obstetrician while they were yet within the 



224 



GYNECOLOGY. 



body of the mother. The injury may be a free incision, a ragged lacera- 
tion, or a severe contusion. The incision may be produced by striking 
upon a blunt object, the sharp edge of the rami cutting through the over- 
lying tissues. Large vessels may be ruptured without the skin being 
broken, when a severe hemorrhage will occur into the tissues. In the 
former case the hemorrhage will be open; in the latter, concealed. 

Treatment. The injury of vessels and the resulting hemorrhage into 
the tissues are called pudendal hemorrhage (see Vulvar Hematoma). 




Fig. 193. — Knives for Denudation. 




Fig. 194. — -Curved Scissors. 




Fig. 195.— Retractor. 



This may demand evacuation, and the resort to measures for the control 
of the bleeding vessels. 

Severe hemorrhage following an injury should demand an inspection 
of the injured part and measures for its control. Where a large vessel 
bleeds the wound, if necessary, should be enlarged and the vessel ligated. 
Frequently the hemorrhage can be controlled by the sutures used to close 
the wound. Often general oozing from a ragged opening is controlled 
best by gauze pressure. The wound must be cleansed carefully and kept 
in an aseptic condition. 

203. Coition, as is well known, causes a rupture of the hymen which 
guards the vaginal opening. Laceration of this structure is usually cen- 



TRAUMATISMS. 



225 



tral and posterior. It may, however, be bilateral. Occasionally, the 
hymen is so firm as to resist all attempts at coitus, and therefore will 
require incision before the act can be accomplished. 

The entire vaginal canal is more or less dilated by repeated coition, 
as evidenced by the enlarged and roomy canal which distinguishes the 
nulliparous from the virgin vagina. Severe lacerations of the vulva and 
vagina the result of sexual intercourse are rare, except when produced 
by rape of young girls. Instances are reported, however, in which in- 



FiG. iq6.. — Blunt Hook 




Fig. 197. — Doyen Needle Holder. 




Fig. 198. — Needles. 




Fig. 199. — Needle with Loop for Suture. 

juries of gravity have been produced, as tearing off the hymen, per- 
foration of the posterior vaginal wall, rupture of the perineum, forma- 
tion of rectovaginal fistula, and perforation of the posterior vaginal 
fornix. Such injuries are more likely to occur in those who come to 
the first coitus late in life, or in whom there have been premature 
atrophic changes. Skrobanski, however, cites a peasant, aged twenty-two 
years, in whom the first coitus caused a rupture of the perineum, two 
centimeters in depth, but without entering the rectum. R. Abrahams 
reports the history of a woman twenty-six years old, in whom a rectoperi- 
neal fistula was produced which permitted the introduction of two fingers. 



226 GYNECOLOGY. 

Occasionally the first coitus is followed by a hemorrhage so active 
as to endanger the life of the woman. The bleeding is best controlled 
by the introduction of a suture to include the spurting vessel. 

Treatment. Injuries resulting from the sexual act are rarely of sufficient 
importance to demand surgical interference. If severe, the treatment 
will depend upon the character and extent of the injury. An extensive 
laceration should be sutured. The sexual act should be discontinued 
until the injured parts have fully recovered, and then should be practised 
with the utmost gentleness and care. 

204. Parturition. Maternity is not without its penalty. The 
great majority of injuries to which the genital organs are subject occur 
during or as the result of labor. The injuries are due to faulty anatomic 
conditions, as distorted pelves, rigid, unyielding muscles, inflamed and 
undilatable cervices, abnormal positions of the fetus, disproportion between 
its size and that of the pelvis, violent uterine contractions, long-delayed 
and feeble contractions, and premature or too long postponed instru- 
mental or manual interference. 

The long-continued pressure of the fetal head impacted in the 
pelvis is probably even more disastrous than the premature 
delivery by the application of forceps. Indeed, vesicovaginal fistulae, 
which were of frequent occurrence prior to the intelligent use of the 
forceps, now rarely come under observation. The injuries are of great 
variety and affect the uterus — both body and cervix — the vagina, the 
vulvar outlet, and particularly the perineum. 

205. Injuries of the body of the uterus may occur in the form of 
lacerations of its anterior or posterior wall, in a vertical or transverse 
direction, and may be slight or sufficiently large to permit the escape of 
the fetus and placenta. Following an abortion, the softened uterine wall 
occasionally is perforated by the curet or placental forceps, or both. 
Through such a perforation loops of intestine have been drawn into the 
uterine cavity — even through the os — and subjected to serious injury. 
Injuries of the uterine body are not confined to parturition alone. 
The walls of the inflamed or flexed nonpuerperal organ are perforated 
frequently by the use of a sound, bougie, or other dilator. In the removal 
of fibroid growths, the weakened wall can be opened by the removal of 
the tumor which projected through it, or the fundus uteri can become 
inverted and be incised in its removal. 

Treatment. The proper treatment of rupture of the uterine wall 
during labor will be found in the text-books on obstetrics. Perforation 
of the softened walls of the uterus may occur readily in the effort to remove 
decomposing placenta or membrane during an abortion, and should 
demand careful subsequent observation. The retained fragments should 
be removed, where possible, by the finger; placental forceps should be used 
only with the finger as a guide. Evidence of perforation as presented 
by bringing a coil of intestine to the os should require careful return of 
the knuckle of the intestine and the operator should be absolutely certain 
that it has been pushed entirely through the uterine wound, when he may 
pack the uterus with iodoform gauze. 



TRAUMATISMS. 



227 



The appearance of shock, marked disturbance of temperature, con- 
tinued and severe irritation of the stomach, or other indications of peri- 
tonitis should be recognized as urgent indications for abdominal section. 
Perforation of the uterine wall by sound or bougie, unless associated with 
severe infection has but little significance. However, irrigation with 
irritating fluids is to be avoided and drainage of the uterus must be 
secured by gauze. Rupture of the uterus during removal of fibroid 
growths should be considered an indication for immediate closing of 
the wound through an abdominal section. 

206. Injuries of the cervix uteri are described under the term 
laceration. Laceration of the cervix is the most frequent lesion of labor. 
It is exceedingly rare for a woman to undergo her first parturition with- 
out tearing of one or both sides of the cervix. The tear may vary from 
a slight fissure, which completely disappears during convalescence, to 
an extensive laceration, extending to or into the vaginal fornices. 





Fig. 200. — Slisfht Fissure of Cervix. 



Fig. 201. — Extensive Laceration of 
Cervix. (Munde). 



Lacerations of the cervix are unilateral, bilateral, stellate, or through 
the anterior or posterior lip. The bilateral is the most frequent. The 
unilateral is found more frequently upon the left side, owing to the greater 
preponderance of the left occipito-anterior position. Lacerations can 
occur into the cellular tissue laterally, or into the bladder in front, and 
in the latter cause a vesico-uterine fistula. (See Section 216.) The 
cicatrization of a lateral tear may produce a band or bridle which tilts 
the fundus uteri to the opposite side. 

Symptoms. Laceration of the cervix presents no special or specific 
indications of its existence. The symptoms are those produced by the 
complicating conditions. The lesion causes subinvolution and a con- 
sequent increased weight. A bearing-down sensation, discomfort in 
standing or walking, and pain in the sacrum and iliac regions are common. 
The lower level maintained by the organ and the traction of the vaginal 
wall upon its lips lead to separation of the latter, eversion of the cervical 
mucous membrane, thickening of the tissue from its exposure, and fix- 
ation of the everted lips. Irregular or excessive menstruation, or metror- 
rhagia, is not infrequent. Bleeding is excited by locomotion, coition, 



228 



GYNECOLOGY. 



or sexual excitement. The endometritis causes a profuse leukorrhea, 
which constitutes a double drain. The cicatricial bands and everted 
lips not only permit a depression of the uterus in the pelvis, but produce 
either lateral version or retroversion, according to the unilateral or bi- 
lateral character of the lesion. The efforts at repair of lacerated surfaces 
results in the formation of extensive scar tissue in the angles of laceration 





Fig. 202. — Bilateral Laceration of 
Cervix. (Munde.) 



Fig. 203. — Slight Stellate Laceration 
of Cervix. (Munde.) 



which is often associated with profound neurotic or reflex phenomena. 
These frequently are benefited by proper surgical measures. Not 
infrequently neurasthenia may be engendered by pressure of the cicatri- 
cial tissue upon the nerve filaments. Pressure against such indurated 
tissue aggravates the discomfort. 

Diagnosis. A laceration of the cervix is readily recognized by the 




Fig. 204. — Extensive Stellate Lacera- 
tion of Cervix. (Munde.) 




Fig. 205. — Laceration of Cervix with 
Hypertrophy and Eversion of Cervical 
Mucous Membrane. (Munde.) 



finger, but its apparent presence must not be accepted as proof positive 
of previous pregnancy, for a congenital fissure can exist which will permit 
as marked an eversion of the lips as would be produced by a deep bilateral 
tear. The finger will disclose the condition of the lesion, the extent of the 
tear and of its cicatrization, the eversion of the lips, the presence of erosion 
(disclosed by its soft, velvety feel) , or the existence of eversion of the cer- 



TRAUMATISMS. 229 

vical mucous membrane. Inflammation and obstruction of the glands of 
Naboth will be revealed by small, shot-like masses studding the cervix. 
As the finger is passed upward the lips are found to spread out, like the 
top of a celery stalk, but hard, dense, and fixed. 

The bivalve speculum, in drawing upon the anterior vaginal wall, 
aggravates the eversion. The tubular speculum flattens the surface fre- 
quently, removes all trace of the fissure, and leads to its being mistaken for 
granular erosion. The Sims or some retraction speculum affords the best 
exposure. Seizing each lip with a tenaculum and drawing them together 
discloses the extent of the tear. (Fig. 206.) The surface of the tear is 
sometimes covered with exuberant granulations which bleed upon the 
slightest touch. (Fig. 205.) These phenomena, with a profuse and 
sometimes offensive discharge, often renders the differentiation from 
epithelioma exceedingly difficult. The diagnosis may be established by 
the results of treatment, or, better, by microscopic examination of a sec- 
tion of tissue. 

Treatment. Immediate examination after labor to ascertain the extent 
of the laceration is generally impracticable because the cervix is so 
drawn out and thinned that it is difficult to determine the injury. 
The majority of small lacerations close spontaneously under the use of 
ordinary antiseptic precautions. The occurrence of severe arterial hem- 
orrhage should require an examination to ascertain its source, and, when 
found, the hemorrhage is best controlled by suturing the lacerated surfaces. 
Not every laceration requires an operation, and if not done within ten days, 
three months should pass before it is repaired. I quite agree with 
Dickinson that the period of choice for operation is five to seven days 
following the occurrence of the injury. Then involution has taken place 
sufl&ciently to permit the lesion to be disclosed, and operation favors 
normal involution, thereby lessening the danger of endometritis and other 
complications. Small fissures which are inclined to close, or have cica- 
trized, do not require an operation. When the lesion is complicated with 
endometritis, the latter should be treated. Operation in slight cases is to 
be condemned, as it obstructs drainage and may be the cause of extension 
of disease to the tubes and pelvic peritoneum. Repair is indicated in 
deep laceration; in eversion with hypertrophy and cystic degeneration of 
the mucous membrane; in cicatricial formation at the angles of the fissure 
associated with nervous phenomena; and in subinvolution and endo- 
metritis. Surgical interference should not be employed for slight lacera- 
tions, nor those which have cicatrized, in tubal or periuterine disease, ex- 
cept when associated with abdominal section to correct the complication. 

Complications. The presence of endometritis, associated with marked 
eversion and hypertrophy of the mucous membrane, requires treatment 
prior to operation for cervical laceration. The patient's diet should be 
regulated, constipation corrected, and appropriate measures instituted to 
relieve the accompanying anemia. She should be permitted to take twice 
daily a vaginal douche of hot water containing an ounce of rock salt to the 
quart. The cervix should be scarified or punctured, thus securing de- 
pletion. All obstructed Nabothian glands should be punctured and the 



230 GYNECOLOGY. 

gland cavity painted with Churchill's tincture of iodin, a combination of 
tincture of iodin and creasote (2:1), iodin crystals dissolved in 95 per cent, 
carbolic acid solution, silver nitrate (5j to fgj), zinc chlorid (3j to f^j)) 
or a solution of argyrol, or pyroligneous acid. The superfluous material 
should be sponged away and a tampon of gauze and cotton applied 
beneath the uterus. The organ thus raised to a higher level the sensation 
of weight or heaviness is removed and the circulation is improved. 

The tampon may consist of plain sterilized gauze and cotton, or gauze 
medicated with iodoform, carbolic or boric acid, or thymol. Sublimated 
gauze should not be used as it irritates the vagina and causes pruritus. 
The tampons may be medicated with preparations of glycerin, a 50 per cent. 

I^. Alum 3 j 

Acid, carbolic, §iv 

Glycerin 3 xi j 

solution of boroglycerid, the official iodoform ointment, or a 10 per cent* 
solution of ichthyol. In place of the glycerin the tampon may be medicated 
with an ointment, such as 25 per cent, of ichthyol in lanolin. The local 
treatment, associated with a tampon, should be employed twice a week, 
and the tampon removed at the end of forty-eight hours, to be followed 
twice daily by a vaginal douche of half a gallon of hot salt water (tempera- 
ture from 1 10° to 1 20° F.) . The douches are preferably given with a foun- 
tain (gravity) syringe, while the patient is in a recumbent position on a bed- 
pan. Where the cervix and the neighboring tissues contain a large amount 



Fig. 206. — Blunt and Sharp Curets. 

of inflammatory exudate the bulb (Davidson) syringe, by force of its 
current, exercises a salutary influence in promoting absorption. A profuse 
discharge of glairy mucus from the surface should be removed with a 
blunt curet or sucked off with a syringe. The curet presses, or the syringe 
draws, the mucous collections from the cervical glands and permits the 
application to come directly in contact with the diseased surface. The 
medicament may be applied by means of a cotton wrapped probe, 
carried into the canal with a pipet, or a few drops may be introduced with 
a Braun syringe. However, intracervical or intrauterine applications 
should not be made, unless the cervical canal is quite patulous, so that 
the fluid or increased serous discharge can escape readily. If the canal 
is obstructed by hypertrophied and everted mucous membrane, gauze 
packing, or the use of a laminaria tent, (Section 56) will render the ap- 
plication more effectual and safe. Irregular bleeding or profuse leukor- 
rhea should indicate the use of the sharp curet and dilatation. 

The uterus should be irrigated during or following curetment with a 
disinfectant solution, bichlorid, i : 3000; formalin, i : 1000, a hot soda solu- 



TRAUMATISMS. 



231 



tion, 4 drams to 2 pints, or preferably with i per cent, salt solution, and 
swabbed with a saturated solution of iodoform in ether. If for any reason 
there is much bleeding following the procedure, the uterine canal should 
be packed with iodoform gauze. 

207. Trachelorrhaphy (that is, neck-sewing), or hysterotrachelor- 
rhaphy (that is, womb-neck sewing), is an operation devised by Emmet 
for the relief of laceration of the cervix. The patient, prepared (Section 
131) and anesthetized (Section 137), is placed upon a table in the lithot- 
omy position, with a perineal pad beneath her buttocks to carry the irri- 
gating fluid into a slop-jar at the end of the table. Each leg is held by 
an assistant or secured by a leg-holder. The following sterile instruments 
(Section 125) have been placed in 
a tray upon a table at the opera- 
tor's right: a scalpel or bistoury; 
curved scissors; long, rat-toothed 
dissecting forceps; two double 
tenacula; a retraction speculum 
(Edebohls'); six pressure forceps; 
a needle-holder; four strong 
needles, curved and bayonet- 
pointed, each threaded with a 
loop of silk to serve as a suture 
carrier. A smaller tray will con- 
tain the suture material. My 
preference for sutures is chromic 
catgut, which has the advantage 
that it does not have to be re- 
moved (Section 127). The nurse 
at the operator's left should have 

charge of the sponges. These should preferably be sterilized gauze, 
though absorbent cotton wet with sublimate solution, 1:2000, can be 
employed. A fountain syringe, filled with hot normal salt solution or 
some disinfecting fluid, should be suspended, so that the field of operation 
can be kept clean by constant irrigation. The final preparation of the 
patient (Section 131) completed, the cervix is exposed with a speculum, 
and each lip so seized with a double tenaculum as to turn in the everted 
edges when the lips are apposed. (Fig. 207.) The assistant upon the 
operator's left holds the anterior lip by the tenaculum and controls the 
irrigation tube; the one upon the right attends to the necessary sponging. 
The posterior lip is held by the weight of the tenaculum. With the knife 
the operator cuts through the cicatricial angle, and in a bilateral laceration 
with scalpel and forceps denudes a corresponding surface upon each lip, 
first upon the left, then upon the right. The knife is preferred to the 
scissors, as the denudation can be made more evenly and with less bruising 
of tissue. The denudation is, of course, limited to one side in a unilateral 
tear. Where a bilateral tear is slight on one side and deep on the other, 
the denudation should be confined to the latter. 

A strip of undenuded mucous membrane, one centimeter wide. 




Fig. 207. — Edges of Laceration Turned by 
Tenaculum Hooked into Each Lip. 



27,2 



GYNECOLOGY. 



should be left in each lip for the future cervical canal (Fig. 208) , and the 
precaution should be exercised not to encroach upon the vaginal surface 
of the cervix in the removal of the tissue. In deep lacerations the circular 





Fig. 



208. — Denudation of Lacerated 
Cervix. 



FiG. 



209. — ^Surfaces Denuded Ready for 
Union. 





Fig. 210. — Sutures Introduced. 



Fig. 211. — Sutures Tied. 





Fig. 212. — Double Flap Amputation of 
the Cervix. (Auvard.) 



Fig. 



213.- 



-Sutures Introduced. 
(Auvard.) 



artery may be opened in the denudation. It should be seized with pres- 
sure forceps, and the first suture should be so introduced as to control it. 
The sutures are placed by introducing the needle about three milli- 
meters from the vaginal edge of the wound, bringing it out at its cervical 




TRAUMATISMS. 233 

margin, introducing it at a similar point in the other lip, and bringing it 
out in the vagina. Ordinarily, three sutures will be sufficient upon each 
side. Occasionally the laceration will be so deep that the angle suture 
cannot be placed properly by passing the needle as we have just described. 
Then it is introduced preferably from within outward, which can be done 
by carrying the ends of the suture, by means of the carrier, through first 
the posterior and then the anterior lip, or with two needles threaded with 
carriers, each passed from within outward, the one anterior and the other 
posterior. One carrier can be passed through the loop of the other and 
drawn out. The loop thus carried through 
serves to carry the suture. The sutures 
are tied, superficial sutures are introduced, 
if needed, and the vagina is thoroughly 
irrigated. If bleeding should continue, a 
suture should be introduced well above the 
denudation to control the bleeding vessel. 
Avoidance of subsequent hemorrhage is 
particularly desirable if a plastic operation 
is to be performed upon the vaginal outlet 
also. 

208. Amputation of the cervix is to r- ^^ ^ n^ ^ 

-^ . . Pig. 214. — Wound Closed. 

be preferred when the cervix is much elon- 
gated and hypertrophied, when the mucous membrane has become exten- 
sively hypertrophied and everted, or when cellular proliferation justifies 
the suspicion of incipient malignant degeneration, although when the 
latter condition is established, complete hysterectomy should be advised. 

The amputation can be made by the double or single flap method for 
each lip. The instruments and preparations are similar to those given in 
the previous section (Section 206). 

Double Flap Operation. The lips of the cervix are seized and separated 
by double tenacula; an incision is made in each angle to the point at which 
it is desired to make the amputation. A wedge-shaped piece is removed 
from each lip, forming cervical and vaginal flaps. Two sutures are then 
introduced in each lip, uniting the cervical and vaginal mucous membranes. 
On each side a suture is passed in through the anterior vaginal and cer- 
vical flaps, out through the similar posterior flaps, and external to this 
such sutures are inserted as are necessary to bring in apposition the raw 
surfaces. The sutures are tied and superficial sutures introduced, if 
necessary, to adjust the edges of the wound nicely. The more accurate 
the adjustment, the less wfll be the subsequent contraction. 

Single Flap Method. Schroder's operation consists in making the denu- 
dation at the expense of the internal or cervical portion of each lip. This 
operation is preferable when the cervical mucous membrane is so diseased 
and hypertrophied as to render its retention for the formation of a flap 
undesirable. In this, as in the former operation, a lateral incision is 
made and the lips are everted. Instead of a cervical flap a transverse in- 
cision is made into the lip from within outward, at the level of the lateral 
incision, cutting half through the lip; then a vertical incision to the junction 



234 



GYNECOLOGY. 



of the cervical and vaginal mucous membranes. Two sutures unite the 
end of each flap to the corresponding cervical mucous membrane, and the 
remaining raw surfaces are adjusted by lateral sutures. 

After-treatment does not differ in the various operations upon the cervix. 
In the use of the chromic catgut suture no provision is made for its removal, 
but it is important to prevent its becoming infected. Unless the vaginal 
outlet is to be the seat of an operation, the vagina should be packed loosely 
with gauze, which should be removed in two or three days. The patient 
is kept in bed for two weeks, and then gradually permitted to resume her 




Fig. 215. — -Schroder's Single Flap Operation. 



ordinary duties. Any pain should be relieved by the application of an ice- 
bag to the abdomen. The patient should void her urine, and the catheter 
should be used only when it is impossible for her to empty her bladder 
while in the recumbent posture. Secure an evacuation of the bowels at 
least each alternate day. Avoid vaginal douches for the first forty-eight 
hours, affording the plasma opportunity to glue the apposing surfaces; 
then use a douche of hot sublimate solution (1:3000), formalin (1:1500), 
or what is preferable a i per cent, saline solution twice daily. 

Direct the patient to avoid worry or much exercise during the next 
menstrual period, and not to resume the sexual relation for one month. 

209. Lacerations of the Vagina. Small tears of the anterior, poste- 
rior, or lateral wall of the vagina are not infrequent, and result in cicatrices 
which produce more or less disturbance of the pelvic functions. Sepa- 



TRAUMATISMS. 



235 



ration of the muscular wall can occur without lesion of the mucous mem- 
brane. Not infrequently the entire vagina is crowded away from its mus- 
cular attachments, so that it subsequently appears as a relaxed sac, falls 
into folds which drag upon the cervix, displace the uterus, or, when it is 
fixed, produce hypertrophic elongation of the cervix. The most fre- 
quent lesions are at the vaginal outlet, and involve that portion of the pel- 
vic floor known as the perineum. These lesions of the vagina are so 
intimately associated with, and dependent upon, the condition of the 
perineum that their treatment will be discussed with the lesions of the 
latter, under the head of injuries of the pelvic floor. Lesions of the genital 
canal, especially of the cervix and vagina, may be induced by long-con- 
tinued pressure of the head of the child during a protracted labor. The 
loss of tissue vitality will necessarily be dependent upon its severity and 
duration. 

The loss of vitality may involve only the superficial structures, as an 
erosion or superficial sloughing, when the tissues may be regenerated. 




Fig. 216. — Schroder's Operation Completed. 



If more extensive, there results contraction and stenosis or partial or com- 
plete obliteration of the canal, known as acquired atresia. This most 
frequently follows injuries occurring during parturition, but it can be pro- 
duced by irritating injections and severe inflammations. Atresia vaginae 
often occurs as a sequel of senile vaginitis. In one patient I found the 
entire vagina obliterated. The symptoms of such a condition are neces- 
sarily dependent upon the time of lif^ at which it occurs. When it follows 
senile vaginitis, it often produces no symptoms outside those of marital 
inconvenience. During the menstrual life of the woman the symptoms 
are similar to those of the congenital variety. The patient suffers from 
menstrual molimina and a pelvic tumor follows. When the vagina is the 
seat of atresia, the condition is easily recognized, as is the uterine accu- 
mulation, if the obliteration occurs at the external os. When the oblitera- 
tion occurs at the internal os, however, and the cervix is apparently normal, 
the diagnosis is more difficult, and the disorder may be confounded with 



236 GYNECOLOGY. 

fibroma uteri, malignant disease, or pregnancy. An analysis of the 
patient's history, associated with careful examination, should afford a 
reasonable suspicion as to its character. 

FISTULiE. 

210. Fistulae. Deep sloughs or extensive tears involving a portion of 
the genital tract not infrequently lead to perforation of one of the adjoining 
viscera, and then we have a fistula. The anterior wall is the most fre- 
quently affected, and consequently results in a urinary fistula, which may 
involve urethra, bladder, or ureter, or be associated with extensive de- 
struction of vagina and cervix. Fistulae are divided into urinary, fecal, atid 
genital. 

The genito-urinary fistulae are : 

1. Urethrovaginal. ] 

2. Vesicovaginal. | 

3. Vesico-uterine. \ (Fig. 217.) 

4. Ureterovaginal. | 

5. Utero-ureterine. J 
The fecal fistulae are: 

1. Ano vulvar. 1 

2. Rectovaginal. [ (Fig. 217.) 

3. Entero vaginal. J 
Genital fistulae are: 

Anomalous openings in the cervix between the cervix and vagina. 
(Cervico-vaginal) . 

Etiology. Fistulae are most frequently caused by the accidents of labor. 
These lesions are of less frequent occurrence than formerly. Improved 
methods of delivery expedite the progress of the fetus, save the maternal 
parts from long protracted pressure, and reduce the danger. Fistulae 
are rarely the result of tearing, but generally follow a slough. Awkward 
use of instruments can result in perforation of the bladder, or rectum, or 
sever an ureter; but such lesions, except the last, present a marked tendency 
to spontaneous recovery. 

Other causes of fistulae are cancer involving the anterior or posterior 
vaginal walls, tuberculous disease, surgical operations, ulceration from the 
presence of a vesical calculus, the pressure of a pessary, abscesses or 
phlegmons. 

Symptoms. The presence of a fistula communicating with the urinary 
tract is recognized by incontinence of urine and by the appearance of urine 
in the vagina. A fistula entering the intestine will permit the discharge of 
liquid feces and gas. A few days subsequent to her confinement the 
patient complains of being unable to retain her urine, or possibly it may 
come with a gush, following the partial or complete separation of a large 
slough. The parts are afterward continually bathed with urine, the 
skin becomes reddened and irritated, and the salts of the urine are de- 
posited, increasing the irritation. The clothing of the patient is saturated 
with decomposing urine, causing a disgusting odor. Partial continence 



FISTUL.E. 



237 



may be present if the opening is small, situated high in the vagina, or affects 
but one ureter. The influence of an intestinal fistula depends upon its 
size and situation. A small opening may permit the escape of the contents 
of the bowel only when they are liquid. The odor of the vaginal secretion 
is exceedingly offensive, so that the patient suffers an enforced retirement. 
Diagnosis. Incontinence should at once cause fistulae to be sus- 
pected. Large fistulae are readily recognized by vaginal palpation. 
Small fistulse, associated with cicatricial contraction of the vagina, are 
often difficult to inspect. The entire surface of the vagina should be 
exposed with retractors or with a Sims' speculum under a good light. If 
the opening is small, it will be revealed by injecting the bladder or rectum 
with milk or other colored liquid, when the opening will be observed as it 
escapes into the vagina. 




Fig. 



-Scheme Sho^Ying Various Fistulae. 



This procedure aff'ords a means for dift'erential diagnosis between 
ureteric and vesical fistulae and between the rectal and enteric. The 
escape of clear urine into the vagina when the bladder is filled with a 
colored liquid demonstrates the ureter as the origin of the fistula. The 
introduction of a ureteral catheter into the sinus and of a sound into the 
bladder permits the recognition of the intervening septum. If the opening 
is small and not visible, dry the surface and apply blotting-paper while the 
bladder is being filled. The paper will be moistened at the site of the 
fistula (Pozzi). The same object can be attained by packing the vagina 
with sterile gauze and injecting the bladder with colored fluid. The stain 
on the gauze will indicate the situation of the opening. In enteric fistulae 
the vagina is constantly bathed with liquid feces, and the appearance of the 
discharge is not affected by rectal enemas. There is an offensive vaginitis 
and the patient suffers from inanition. In supposed uretero-uterine 
fistula the position of the ureters should be examined by Sanger's method. 



238 



GYNECOLOGY. 



(See Section 57.) It has been suggested that the patient urinate, then sit 
two hours upon a vessel, when a catheter is used; and if the quantity thus 
secured is equal to that in the vessel, there is a ureteric fistula. The 
collection has been obtained from separate kidneys. The two kidneys, 
however, do not secrete equally, and the distention of the bladder renders 
such a procedure unnecessary. 

A fistula of one ureter may be inferred when, in spite of the periodical 
passage of urine through the urethra, the vagina is constantly bathed with 




Fig. 218. — Large Vesicovaginal Fistula with Prolapse of the Anterior Vesical Wall through 

the Opening. 



urine; a vesical fistula near the neck may permit of no accumulation of 
urine, while a small one in the upper part of the vagina may allow soiling 
of the latter canal only when the patient is recumbent. In the upright 
position the desire to evacuate occurs before it reaches the level of the 
fistulous opening. 

The most ready method of recognizing the ureteric fistula is by in- 
jecting the bladder with colored fluid. The continuation of uncolored 
fluid in the vagina demonstrates that we are not dealing with a vesical 
opening. 



FISTULA. 



239 



No operation should be attempted for rectal fistula without exclusion 
of rectal stricture. 

Prognosis. The curability of a fistula depends upon its cause, 
situation, size, and duration. Those produced by cancer are a part of the 
progress of the disease, and are incurable unless the disease can be re- 
moved. Spontaneous recovery of a punctured or incised fistula is prone to 
occur under proper cleanliness, but an old sinus with hard, cicatricial edges 
requires surgical interference. An opening in the base of the bladder is 
more readily relieved than one in the upper part of the vagina or one in the 




Fig. 219. — Denudation of the Edges of the Fistula. 

urethra. Vesico-uterine fistulae are particularly difficult, and the uretero- 
vaginal and uretero-uterine fistulae are most trying. 

Treatment. The methods of treating vaginal fistulae as now recog- 
nized may be considered as: 

1. Cauterization. 

2. Denudation and suture of the edges of the fistula. 

3. Flap-splitting, flap-sliding, and suture. 

4. Flap-formation and sutures. 

Cauterization is applicable only to fistulae of small size and where 



240 GYNECOLOGY. 

but little cicatricial tissue exists. The thermocautery is the preferable 
means, although caustic potash, chlorid of zinc, or one of the stronger 
acids can be employed. 

Preliminary treatment is important, whatever the method of operative 
procedure. The urine should be rendered non-irritating by the administra- 
tion of benzoin salts or salol. 

I^. Ammon. benzoat., 3iij 

Tinct. hyoscyami, f 3iss 

Ext. buchu, ' ... ad f Bij. M. 

SiG. — f 5j in water three or four times daily. 

This prescription should be accompanied by the ingestion of large 
quantities of water. Salol, gr. ij-iij, may be given with a glass of hot water 





U 






'J^/ 


i 




''Wk/'^ 




ii 


%a^% 




m 


rani 1 


k 


% 




1 


M 






■ i,i 




/ 



Fig. 220. — Sutures Introduced. 



three or four times daily. Hot or soothing vaginal douches should be 
freely employed, such as a solution of sodium hyposulphite (3iv, aq. 
Oj) or weak solutions of the lead salts. If there is an incrustation of the 
lime salts about the orifice and over the vagina, employ a solution of dilute 
nitric acid (gtt. j, mucilage water fgj). Cicatricial bands should be in- 
cised and stretched; the vaginal walls should be incised to diminish traction 



FISTULA. 



241 



upon the edges of the fistula when sutured. The cicatrization may be 
overcome by having the incisions heal while a Gariel pessary or a col- 
peurynter is w^orn. Bozeman employed vaginal obturators of plated 
copper, which, when worn, distended the vagina and gave more room for 
operation. The intestinal canal should be thoroughly evacuated. 

211. Vesicovaginal Fistula. Injuries of the vesicovaginal septum 
occur more frequently undoubtedly for the reason that its tissues are in a 
situation to be caught more readily between the advancing head and the 




Fig. 221. — Wound Closed. 



pubic symphysis. The operation of vivifying and suturing the edges was 
revived, perfected, and rendered successful by Sims. After thorough 
cleansing and disinfection of the vagina and the bladder the patient is 
placed either in the semi-prone position, or on her back with the limbs 
well flexed. Occasionally the fistula may be rendered more accessible 
by having her lie upon the abdomen with the pelvis elevated. The 
perineum is retracted and the edges of the opening are rendered tense by 
suitably applied double tenacula, which are held by assistants. The 
denudation is performed with knife or scissors, preferably the latter, as the 
tissues bleed less. The denudation is accomplished at the expense of the 
16 



242 



GYNECOLOGY. 



vaginal surface, exercising care to avoid injury to the vesical mucous 
membrane. The mucous membrane is seized with forceps at one side 
and the denudation is performed with the attempt to complete the circuit 
with the one strip. Having secured an equal denudation upon all sides, 
about one centimeter in width, the sutures are introduced. They are 
inserted about one centimeter apart, introducing and bringing them out 
about five millimeters from the edges of the denudation without permitting 
any suture to penetrate the vesical mucous membrane. The sutures may 




Fig. 222. — Method of Suturing to Decrease the Tension upon the Sutures. 

be introduced so as to close the fistula on an anteroposterior, transverse, 
X or Y shaped line or lines, according to the opening, that direction being 
chosen which will produce the least traction on the tissues. The sutures 
may be of silk, catgut, silkworm gut, or silver wire. The last two are 
preferable in denudation operations. After the sutures are all in place the 
bladder should be irrigated in order to remove all clots, and the sutures 
should be tied, twisted, or secured with perforated shot, exercising care 
not to draw them so tight as to strangulate the tissue enclosed. 

After the fistula is closed, it is well to inject the bladder to make sure 
that no small opening remains. In large fistulae, care must be taken not 



FISTULA. 



245 



to injure or constrict the orifice of a ureter. If they open at the margin of 
the fistula, the orifice of the ureter should be enlarged on the vesical side 
several days prior to the operation and dilated by frequent passage of a 
probe. 

212. Flap Splitting or Flap Sliding. The loss of structure by 
denudation in large fistulae is not infrequently a serious sacrifice of tissue, 
and has led to the practice of securing fresh surfaces by splitting the edges 
of the fistula. The vesical and vaginal surfaces are divided through the 




Fig. 223. — Sho\\ing Continuation • of Su- Fig. 224. — Wound Closed, 

turing to Close Fistula with Incisions 
to Decrease Tension with Suture 
Introduced on Left Side to Close the 
Secondary Opening. 

cicatrized margin to any required depth, according to the size of the fistula. 
When the opening is small, it can be closed by a purse-string suture. The 
suture of silkworm gut or silver wire is passed through the vaginal flap 
within the vesicovaginal septum, and brought out in the vagina directly 
opposite its point of entrance, reintroduced near its exit, and made to 
traverse the remaining side of the opening, and brought out near the 
original entrance. This suture, tied, turns the vaginal flap outward and 
the vesical inward. When the size of the opening renders it desirable to 



244 



GYNECOLOGY. 



close it upon a line, the vesical flaps are closed with animal sutures, pref- 
erably chromic catgut. The vaginal flaps may be closed with silk, silk- 
worm gut, or chromic catgut. 




Fig. 225. — Fistula Preparatory to Splitting into Vesical and Vaginal Flaps. 

Walcher advocates first cutting away the cicatricial tissue, then sepa- 
rating the vaginal and vesical surfaces. This procedure secures greater 
mobility of the internal flaps, which are closed with catgut by the Lauen- 



ilft-^^^ 







Fig. 226. — Demonstration of Flap-splitting. 

Stein stitch. The needle is introduced on the raw surface and brought out 
on the line of demarcation, midway between the raw surface and the 
vesical mucous membrane, and the reverse in the opposing vesical flap. 



FISTULA. 



245 



After these sutures are tied,, closing the bladder, the vaginal flaps are 
sutured. E. R. Corson (Savannah, Ga.) expedites the formation of the 
flaps and the introduction of sutures by the use of a portion of an india- 
rubber ball. A strong silk cord is passed through the shank of a shoe- 
button which has been made to pierce the center of a portion of a rubber 
ball; this, folded, is carried by forceps through the fistulous opening. 
Traction upon the string draws down the opening, exposing its edges. 
The ease with which the vaginal and vesical portions of the septum can be 





Fig. 227. — Suture Introduced into \'esical 
Flap. 



Fig. 228. — Suture Tied in Vesical Flap 
Introduced in ^"agina. 



separated renders flap-splitting a ready method for closing large fistulge. 
This separation can be done with impunity, because the circulation of the 
two surfaces is not interdependent. The incision through the vaginal 
portion is preferably made upon a vertical line. Beginning at one side 
of the fistula, one blade of a suitably curved scissors is inserted between the 
two layers as exposed by the vertical incision (Fig. 225) and carried 
completely around the fistulous opening, and the walls are separated by 
blunt dissection. The dissection may be made with the knife, first by a 




Fig. 229. — Wound Closed. 

vertical incision through the fistula and then dissecting up a large flap on 
either side. When necessary to secure additional tissues to close the 
opening, the separation may extend to and even through the peritoneum. 
In closing a large fistula the sutures in the vesical wall are introduced, 
preferably upon a transverse line. As they are buried they should be of 
chromic catgut or fine silk. The edges of the fistula should be inverted 
into the bladder. Each extremity should be secured by a suture, the end of 



246 



GYNECOLOGY. 



which, left long and used as a tractor, permits the intervening sutures to be 
introduced rapidly, after which each may be tied. These sutures should 
not pierce the epithelial surface of the vesical mucous membrane. The 
closure of the vesical wall should be followed by distention of the bladder 
with a warm saline solution to make sure that it is tight. The vaginal wall 
should then be closed by a vertical line of suturing, which may be con- 
tinuous or interrupted, as the operator prefers. In introducing these 
sutures the bladder surface should be included, to prevent the accumula- 
tion of serum or blood between the surfaces. 




Fig. 230. — Sutures Introduced to Close Vesical Surface, as Suggested by Walcher. 

The fact that the vagina has been so destroyed that it will not afford 
material to cover the vesical wall need not deter the operator from em- 
ploying this method, as flaps can be taken from the labia or from the 
inner side of the thighs to complete the vaginal wall. 

M. C. McGannon, of Nashville, ingeniously closed a fistula in a woman 
who had a laceration of the rectovaginal septum half-way to the cervix. 
The anterior vaginal wall and base of the bladder were gone. He 
dissected the bladder away from the uterus and pushed the peritoneum off 
until he could bring the flap down to the lower segment, and closed it with 



FISTULA. 



247 



fine catgut. After closing the bladder, the surface was covered as much 
as possible with the remaining portion of the vagina. A large surface 
was left uncovered fcr cicatrization. The left ureter had been included 
in the bladder, but the orifice of the right was situated so high in the vagina 
that it was inaccessible. Subsequently it was conducted to the bladder by 
an artificially constructed conduit. A year later her condition was good, 
with perfect control of the urine. 

In extensive fistulae Trendelenburg advocates making a transverse in- 
cision ten centimeters long through the abdominal walls, and a transverse 




Fig. 231. — Flap-formation as Suggested by Ferguson. 

incision through the bladder, just below the peritoneal junction. The 
upper edge of the vesical wound is temporarily stitched to the correspond- 
ing abdominal, and the lower edges of the bladder are held open with 
sutures. The edges of the fistula are trimmed and the sutures so intro- 
duced that their ends can be brought out and tied from the vagina. The 
anterior vesical wound is closed around a drainage-tube, gauze is placed 
in the prevesical space, and both are brought through an opening in the 
abdominal wound, the remaining portion of which is closed with sutures. 
Bardenheuer formed a flap by transplantation. He performed supra- 



248 



GYNECOLOGY. 



pubic cystotomy, and through the abdominal wound dissected the bladder 
away from the peritoneum as low as the fistula, separated the adhesions 
and cicatricial tissue, denuded the edges of the fistula and sutured them 
from the vagina, while the edges of the fistula were pressed together by 
the finger passed into the bladder through the suprapubic wound. The 
abdominal wound is plugged with gauze and left open. By utilizing a 
vesical flap the operation can be performed through the vagina, as 
described above. 




Fig. 232. — Flap Turned in and Vesical Opening Closed. 



213. Flap formation is a procedure practised by Ferguson, of Chicago, 
and E. Stanmore Bishop, of Manchester, England. Ferguson made an in- 
cision with a scalpel through the vaginal mucous membrane three to six 
millimeters from the margin of the fistula. (Fig. 231.) This incision 
completely encircled the opening and extended to the vesical wall, but did 
not injure it. 

The wound was kept free from blood by a stream of sterilized water. 
This procedure formed a circumferential flap, hinged by the vesical mu- 
cous membrane, which, turned into the bladder, formed a roof for the raw 
surface and was held in that position by a continuous fine chromic catgut 



FISTULA. 



249 



suture so inserted that it did not pierce the mucous wall of the organ. 
(Fig. 232.) The narrow strip of vaginal tissue, which from its density 
retained the stitches well, became a part of the bladder-wall. Thus the 
fistulous opening was closed and made water-tight. The operation was 
completed by suturing the vaginal walls with silkworm gut or preferably 
silver wire. (Fig. 233.) Bishop ingeniously inserts four sutures into the 
edges of the flap as constructed by Ferguson, and with a pair of forceps 
passed through the urethra drags these sutures, previously knotted, out 




Fig. 233. — Introduction of Vaginal Sutures. 



through that canal. The funnel thus formed is closed with a suture from 
the vagina and the vaginal walls are sutured over it. The advantages 
justly claimed for this plan are: first, there is no loss of tissue; second, a 
broad surface is secured for apposition; third, there is a projection into 
the bladder at the site of the opening which decreases the danger of leak- 
age and infection; fourth, in case the ureter opens into the fistula, it affords 
an excellent opportunity to turn it into the bladder; fifth, it decreases the 
danger of primary and secondary hemorrhages; sixth, in large openings 
it affords the best opportunity to secure relaxation by incision or sliding 
flaps; seventh, it is applicable to fistulas of the bladder, urethra, or rectum. 



250 



GYNECOLOGY. 



After-treatment. The vagina, thoroughly cleansed, should be packed 
lightly with iodoform gauze, which should remain for two or three days. 
Continuous drainage should be secured by the introduction of a self- 
retaining catheter into the bladder. This should be removed daily, for 



,X 



J^'^' 



/ 





Fig. 234. — Section Showing Projection upon Vesical Surface. 




Fig. 235. — Self-retaining Catheter. 




Fig. 236. — Vesico-uterine Fistula. 

the purpose of cleansing. At the end of eight days it should be removed 
permanently; but the patient should be catheterized four times daily 
for the next week. The vagina should be irrigated with an antiseptic 
solution twice daily after the third day, and this should be continued 



FISTULA. 



251 



for the greater part of three weeks. The sutures should be removed 
on the fifteenth day. 

214. Closure of the Vagina. Colpocleisis. Episiostenosis, 

Large fistulas in which the base of the bladder is destroyed may be in- 
directly obliterated by closure of the vaginal orifice, thus making the vagina 
a part of the urinary reservoir. A ring of tissue two centimeters broad 
is removed from the vaginal orifice. In the dissection the parts should be 
kept on the stretch and the tissue should be dissected from above down- 




Fig. 237. — Colpocleisis. 

ward. A sound in the urethra and a finger of an assistant in the rectum 
will greatly facilitate the denudation of the anterior and posterior walls 
of the vagina. The sutures should be passed from below upward and 
from above downward, exercising the greatest care that neither rectum, 
bladder, nor peritoneum shall be perforated by the sutures. The de- 
nuded surfaces should be brought in accurate apposition and the over- 
lapping of freshened surface with mucous membrane or skin should be 
strictly avoided. This procedure, while it affords a means of relieving 
incontinence of urine in otherwise desperate cases, has many disadvan- 
tages. Impregnation is no longer possible; coition can be practised only 



252 



GYNECOLOGY. 



when obliteration has occurred high in the vagina. The menstrual 
blood not infrequently excites violent cystitis resulting in pyelonephrosis 
and the formation of vesical calculi. The urine may cause metritis or 
tubal, ovarian, and even peritoneal inflammation. Rectovaginal fistula 
has been made to supplement this operation when the neck of the bladder 
has undergone such injury as to render the patient unable to retain the 
urine. The majority of such cases have been unsuccessful, owing to the 
irritation of gas and feces and the inclination of the fistula to close. The 




-^ 




Fig. 238. 



-Closure of Fistula after Its Exposure by Incision through Anterior Vaginal 
Fornix. 



fistula which cannot be closed by flap-sliding is very rare, as the vesical 
and vaginal surfaces are separated easily and the vaginal wall when de- 
ficient can be replaced by flaps from the vulva and inner sides of the thigh. 

215. Urethrovaginal fistula is very infrequent. It is characterized 
by the discharge of urine into the vagina during micturition. The flap- 
splitting operation affords the most satisfactory method of closing it. 

216. Vesico-uterine fistula permits the escape of urine through the 
external os. It may result from a slough following a tedious labor, and 
from lacerations of the cervix when the tear has extended through the an- 



FISTULA. 



253 



terior lip. The tear may have been incomplete, not extending through the 
OS, or the fissure may have healed with the exception of the communication 
between the bladder and cervix. The only condition with which such a 
fistula can be confused is the uretero-uterine. The latter fistula is rare. 
Upon injecting the bladder with a colored fluid (a solution of pyoktanin) 
its emergence from the os demonstrates the presence of a vesical fistula; 
the continuance of clear fluid, a ureteral fistula. In an opening of con- 
siderable size the sound will pass directly into the bladder, where it can 
be recognized by another inserted through the urethra. 

Treatment. The fistula may be exposed by dilating the cervix with 
a laminaria tent. In a uretero-uterine fistula this procedure would be 
accompanied by renal pain, nausea, and vomiting, due to the obstruc- 
tion of urine from the kidney corresponding to the affected ureter. The 





Fig. 239. — Fistula Closed into Vagina. 
Uterine Opening Remains, Whicli 
Will Close Itself. 



Fig. 



!40. 



-Section Showing Suture for 
Hvsterocleisis. 



fistula may be denuded and closed from the cervical canal, but the opera- 
tion is attended with difficulty. The preferable procedure is to cut 
through the anterior fornix of the vagina and dissect the bladder from the 
cervix, when the opening can be exposed and sutured. The vaginal 
wound is subsequently closed with silk or catgut. It is desirable that the 
peritoneum should not be opened, though its incision, with proper pre- 
cautions, does not materially affect the result. When the bladder-wall 
is thin, Herr advises cutting through the cervix and reinforcing the bladder- 
wall with cervical tissue. Sanger split the cervix of a patient in whom 
the sinus opened laterally, sutured the side on which the fistula occurred, 
as in an Emmet operation, and then sutured the other side. 

217. Hysterostenosis or hysterocleisis (Fig. 242), the denuda- 
tion and suturing of the cervix, is possible, but the menstrual flow may 



254 



GYNECOLOGY. 



produce serious cystitis, and contraction of the fistula may result in severe 
pain and distress during menstruation. Both tracts will be subject to 
irritation and ascending infection, producing upon the genital side 
endometritis, salpingitis, and peritonitis; upon the urinary, ureteritis and 
pyelitis. When we consider that the opening can be exposed by dissect- 
ing the bladder from the cervix, one can hardly conceive the selection of 
hysterocleisis as ever justifiable. 

218. Vesico-uterovaginal (Cervical) Fistula* A portion of the 




Fig. 241. — Closure of Fistula within Cervical Canal after Splitting Cervix. 

cervix, with a considerable portion of the vaginal septum, may be destroyed, 
and the remaining walls may be so thin as to render its closure difficult 
or dangerous, owing to proximity of the peritoneum. In such cases the 
anterior lip of the cervix (Fig. 243) may be denuded and turned into the 
bladder, using it as a plug to fill up the opening. 

When the fistula has developed at the expense of the anterior cervical 
lip to such an extent that it will not afford sufficient structure to close the 
opening, the posterior lip may be freshened and utilized. (Fig. 244.) 
This procedure necessarily produces disturbance because of the continu- 
ance of menstruation. A preferable method is to separate the vesical 



FISTULA. 255 

wall from the cervix and secure sliding flaps, which can be closed as in 
figure 245. 

219. Ureterovaginal-ureterocervical Fistulae. Lesions of the 
ureter are less frequent than the other forms of fistulae. Participation of 
the ureter in the vesicovaginal opening is much more frequent. Uretero- 
vaginal fistulse are more frequently the result of injuries sustained during 
the performance of hysterectomy. The diagnosis has been considered. 
(See Section 284.) The cervical fistula is very rare. The thickened 
ureter can be traced generally to the cervix by the finger in the vagina. 




Fig. 242. — Hysterocleisis. 

Relief from the discomfort produced by these fistulae may be accom- 
plished by resort to one of several methods. 

1. The formation of a flap from the anterior vaginal and posterior 
vesical septum which is united to a denuded surface on the posterior 
vaginal wall. 

2. The formation of a vesico-vaginal fistula and such denudation and 
suturing as will convey the urine into the bladder. 

3. Anastomosis through the vagina. 

4. Anastomosis through the abdomen. 



256 



GYNECOLOGY. 



5. Ligation of the ureter. 

6. Introduction of the ureter into the rectum or colon. 

7. Drainage of the kidney through the back, or the establishment of 
a fistula in the lumbar region where a receptacle may be worn conveniently. 

8. Nephrectomy. 

I. The first method of dealing with ureterovaginal fistulae has to do 
with cases in which the lesion had occurred when hysterectomy was 
performed. The uterus having been removed, the only inconvenience 
from the procedure will be a slight shortening of the vagina. The pro- 
cedure suggested by Werder is performed as follows: A bougie, inserted 
into the bladder through the urethra, impinges against the posterior 
vesical wall near the upper part of the vagina. On this landmark, a 
transverse incision is made through the vaginal septum with curved 




Fig. 243 . — Anterior Lip of Cervix Utilized 
to Close the Fistula. 



Fig. 244. — Vesico-uterovaginal Fistula in 
which the Posterior Lip of the Uterus 
is Utilized to Close the Opening. 



scissors or an angular bistoury. The upper end of the vagina having 
been encircled by an incision and the edges separated, the lower lip of 
the transverse incision is sutured to the vagina to throw the undenuded 
portion of the vaginal wall into the bladder. Silkworm gut sutures are 
preferable for this purpose and should not enter any portion of the mu- 
cous membrane which will form a part of the vesical cavity. 

2. The second method involves principles suggested by Simon of 
London. It is used when the fistula affects one ureter and a function- 
ating uterus remains. The first step consists in establishing a vesico- 
vaginal fistula near the opening of the ureter into the vagina. To ensure 
permanence, the vesical and vaginal mucosa must be united by sutures 
and the permanence of the fistula assured before attempting to control 
the incontinence. Ten days to two weeks after the establishment of a 
fistula, an incision is made around the two openings and the upper edges 
sutured without permitting any of the sutures to enter or come out on 
the mucous membrane. These tissues sutured, a conduit lined with 
mucous membrane is formed which convevs the urine from the severed 



FISTULA. 



257 



ureter into the bladder and the raw surface below is covered by a vaginal 
flap. 

3. Vaginal anastomosis, as an alternative, takes cognizance of the 
ureter as a distinct canal capable of being dissected from its bed and drawn 
sufl&ciently to permit of its traction into an opening made into the bladder 
where it is secured by sutures. This procedure is applicable to either 
vaginal or cervical fistulae of this canal. In order to prevent compression 
of the ureter a portion of the bladder-wall should be excised. The ureter 
is introduced into the bladder, the wound is closed carefully with sutures 




Fig. 245. — ^Vesical Wall Loosened and Sutured. \'aginal Wall Sutured in Opposite Direction;. 



introduced to fix the wall of the ureter and thus insure its retention. 
Care should be exercised that the ureter is not compressed, nor much, 
if any, of its surface left uncovered in the vagina. In ureterocervical 
fistulae the cervix should be split until the orifice of the ureter is exposed, 
when that structure can be drawn down and union accomplished in the 
manner just described. Obliteration of the vaginal orifice has been done 
after the establishment of a vesicovaginal fistula, but such a course is 
both unnecessary and undesirable. 

The difficulty of dissection of the ureter in a vagina more or less 
narrowed by cicatricial contraction, and the possible destruction of a 
17 



258 



GYNECOLOGY. 



part of the ureter as a result of the injury, necessarily limits the feasibility 
of this procedure. 

4. Anastomosis through the abdomen may be preferable in such cases, 
or when the lower extremity has undergone inflammatory changes or 
is so embedded in exudation that it cannot be brought down' readily. 
Through the ordinary incision for abdominal section the intestines are 
drawn aside, exposing the line of the ureter. In ureterovaginal fistula 
its situation can be recognized more readily by the introduction of a 
catheter prior to the abdominal incision. The peritoneum is opened, 
the ureter is raised, its proximal portion is tied and dropped back. The 
central end is introduced through an incision into the bladder and secured 




Fig. 246. — Operation for Ureterovaginal Fistula. 



by sutures, as in the vaginal method. The anastomosis with the bladder 
should be on the corresponding side of the pelvis, and with as little tension 
upon the canal as possible. Should the ureter be so short as to cause 
tension in reaching the bladder, the latter should be drawn up and anchored 
by a few stitches to the side of the pelvis, so that no traction shall be 
made upon the ureter. In recent injury an anastomosis can sometimes 
be made between the divided ends of the ureter. The proximal end should 
be introduced into the distal one and secured by sutures. (Fig. 251.) 
The ureter may be tied with a double ligature and dropped back. The 
urine accumulates in the pelvis of the kidney until the pressure equals that 
of the blood, when secretion ceases. The ureter should pass through the 
bowel obliquely. However, this procedure is very likely to be followed by 
serious conditions in both the urinary tract and the intestine. In the 
former, infection and suppuration of the pelvis of the kidney are prone to 
follow. The presence of urine frequently causes irritation and inflamma- 
tion (colitis or proctitis) of the intestine. 



FISTULA. 



259 



5. Ligation of the ureter is done if anastomosis of the ends of the ureter 
or the insertion of the proximal end into the bladder is not feasible. 

6. The divided ureter is introduced into the ascending colon on the 
right, or into the sigmoid on the left. 



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Fig. 247.— Vaginal Implantation of the Ureter into the Bladder. 

7. Drainage of the pelvis of the kidney through an incision in the 

back has been advocated and practised satisfactorily by Watson of 

Boston. One great advantage it affords is that a receptacle' can be worn 

with less discomfort. This plan of procedure is more applicable to cases 

n which it is necessary to sacrifice a good portion of the bladder and the 



26o 



GYNECOLOGY. 



ureters for malignant disease of the pelvic organs. The ends of the 
ureters can be carried out on the back in the lumbar regions and 
afford equal readiness for wearing a receptacle for the urine, but neither 
of these procedures should be elected as long as it is possible to return 
the divided ureters to the bladder. 

8. Nephrectomy is advisable when the long duration of the fistula 
has resulted in extension of infection to the pelvis of the kidney, and 
careful examination has disclosed that the other kidney is capable of 
carrying on the work of both organs. 




Fig. 248. — Abdominal Transplantation of Ureter for Ureterovaginal Fistula. B. Bladder. 

220. Accidents of the Operation and Results. Primary hem- 
orrhage of a serious character may result from an unusually large uterine 
artery, from vascular walls, or from injury of the vesical mucous 
membrane. Either compression or suture is the best means for its con- 
trol, but its occurrence imperils the result of the operation. 

Secondary hemorrhage may take place between the third and fifth 
days, and should be controlled by the tampon. It may occur into the blad- 
der, and may be discovered only after that organ is filled with clot. It gives 
rise to violent tenesmus, and its decomposition will be extremely prej- 
ulicial to the success of the operation. When it cannot be removed 
by irrigation, inject a solution of pepsin or enzymoL If this procedure 



FISTULA. 



261 



fails to afford relief, the urethra should be dilated and the clot broken 
up and removed with a blunt curet. If hemorrhage continues, it will 
be necessary to remove the sutures and search for the bleeding vessel. 

Inclusion of a ureter will cause nausea, vomiting, lumbar pains, and 
fever. The suspected suture should be immediately removed. 

Peritonitis may result from injury during the denudation or suturing, 
or from infection, when proper precautions have not been observed, or 
when there is coexisting pyelitis or cystitis. 




Fig. 249. — Ureteral Anastomosis. 

Calculi and calcareous concretions have formed upon silver wire, silk, 
or even catgut sutures. 

The results of the operation are generally most satisfactory. Death 
is of very infrequent occurrence. 

221. Rectovaginal Fistula. The methods of treatment suggested 
(Section 210) are equally applicable to the fecal fistulae. The last two 
methods, flap-splitting and flap-formation, are probably more effective 
and generally applicable in the great majority. 



262 



GYNECOLOGY. 



In a small fistula a curvilinear or triangular trap-door may be raised, 
including the fistulous orifice; the opening in the rectal wall is closed 
by very fine (eye) silk, which has been sterilized previously, or by chrom- 
icized catgut. One or several Lauenstein sutures may be used, care being 
taken not to enter the rectum. The vaginal flap is then secured with silk- 
worm-gut sutures. In large fistulae a sagittal incision with lateral flaps is 
most satisfactory. The sutures are introduced as previously described. 
Flap-formation is very serviceable in closing rectal fistulse of considerable 
size; flap-transplantation is rarely successful. 









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Fig. 



250. — Sagittal Incision for Recto- 
vaginal Fistula. 



Fig. 251. — Lauenstein Suture in Recto- 
vaginal Fistula through P.ectal Wall. 



222. An anovulvar fistula can be closed from the vagina or perineum. 
Such a fistula is incised through its track, cureted, and the entire sinus 
closed by sutures. It is generally better to extend the incision to, but 
not through, the sphincter, and to close the rectal or anal surface with 
sutures from the perineal side, when failure to unite will not endanger 
the future value of the sphincter and will enable the operator to secure 
union by granulation through gauze packing. Small fistulae near the 
vulvar outlet can be closed as a part of the operation of perineorrhaphy. 

Preliminary and After-treatment. The bowels should be evacuated 
thoroughly by repeated purging for two or three days. During the 
same period vaginal douches should be given, and a thorough scrubbing 
of the vagina with a solution of creolin and soap should immediately 
precede the operation. However, no operative procedure for closing a 
fistula should be entered upon until careful rectal examination has demon- 
strated the absence of a possible rectal stricture as its cause. For several 
days prior to the operation, and for at least a week subsequently, the 
patient should be kept upon an animal broth diet, and the use of milk 
should be prohibited. The operation should be preceded a few hours 



FISTULA. 



263 



by thorough irrigation of the rectum, and continuous irrigation should be 
practised during it. After the third day the bowels should be moved 
each alternate day. The sutures of silk should be removed upon the 
eighth day; silkworm gut or silver wire may be permitted to remain for 
fifteen days. The patient should be confined to bed the greater part 
of three weeks, and the bowels should not be permitted to become con- 
stipated for a month. 

223. Enter ovaginal fistulae have been cured by cauterization, or 
by denudation and suture from the vagina. The readiness with which 
it closes depends on the easy passage of the intestinal contents along the 




Fig 252. — Rectal Wall Closed by Transverse Line of Sutures; Vaginal, by Vertical Line 

of Sutures. 

intestine beyond the opening. Ordinarily the intestine is more or less 
constricted by adhesions so that it is a safer plan to treat such fistulae 
by opening the abdomen, separating the adhesions, and closing the open- 
ing. The opening in the vaginal wall will close itself. 

224. Cervicovaginal Fistula. A cervicovaginal fistula is one which 
arises as a result of rupture of the cervix during labor, from a longitudinal 
tear the lower margins of which have become reunited. The tear may be 
a perforation of one lip of the cervix through which the fetus is extruded, 
and occurs where the cervix is hard, rigid, and unyielding. Such a con- 
dition of the cervix sometimes causes the entire cervix to be torn away. 
A fistula may also arise from faulty methods of repair of the lacerated 
cervix. I have seen such openings on both sides of the cervix where 
trachelorrhaphy has been attempted. The fistula doubtless sometimes 



264 



GYNECOLOGY. 



arises from the use of sharp instruments in attempts at abortion. The 
opening of such a fistula is excoriated and filled with mucus. 

Treatment. The correction of the condition is not always an easy 
procedure. The preferable plan is to incise the cervix through the open- 
ing, denude the margins, and close as in an ordinary operation of trachelor- 
rhaphy, but this is not always practicable and in some cases the amputa- 
tion of the cervix may be demanded. 




Fig. 2! 



-Rectovaginal Fistula Closed in Operation of Perineorrhaphy. 



PERINEUM. 



225. Lacerations of the pelvic floor are a frequent lesion of par- 
turition, and can occur from within outward through the vagina and 
vaginal portion of the perineum, leaving its integumental covering intact. 
The injury is a separation or tearing-off of the muscular fibers from the 
sides of the vagina. Generally, the tear takes place through the integu- 
ment of the perineum. It may extend through the entire structure, 
the sphincter, and up the rectovaginal septum. Not infrequently it 
will be found that the injury has been quite as deep, but on one side of 
the rectum and anus, and leaves both intact. Less frequently it will thus 
extend on both sides of the anus. 



PERINEUM. 



265 



Naturally, the influence upon the subsequent appearance and function 
of the parts must vary with the extent and direction of the laceration. A 
slight laceration which involves only the anterior portion of the perineum 
may heal without producing much deformity, if any. A deeper lacera- 
tion, by the action of the transversus perinei muscles, permits the vaginal 
orifice to stand open, and presents a triangular appearance. The failure 
of the bulbocavernosi muscles to antagonize the coccygeus longer permits 
the anus to be drawn back. 




Fig. 254. — Rupture of Perineum into Rectovaginal Septum. 

Laceration through the sphincter necessarily causes loss of control 
of the bowel-contents. (Fig. 254.) 

The deep laceration to one side of the anus leaves the levator ani 
unantagonized, and the parts are drawn to the opposite side. When 
the tear extends upon both sides, the anus is depressed and drawn back- 
ward. The vulva stands open, and we can look into the vagina from 
three to five centimeters. 

Causes. Injuries of the pelvic floor may arise, first, from conditions 
inherent in the mother; second, in the child; and third, in the course 
and management of the labor. Of the first class may be {a) too great or 



266 



GYNECOLOGY. 



too slight an inclination of the pelvis, which renders the mechanism of 
the fetal head imperfect; (b) a small vulvar orifice with rigid muscles, or a 
large amount of fat in the perineum; (c) high or anterior situation of the 
vulva, making a long perineum, over which the child's head must be 
extended. 

Second, laceration may result from excessive size of the fetal head and 
shoulders, or from relative disproportion to the size of the mother. 

Third, laceration may result from (a) either too rapid or too tedious 
labor; (b) vertex presentations when rotation occurs into the hollow of 




Fig. 255.— Incomplete Rupture of the Perineum. 



the sacrum and an occipitoposterior position presents a longer diameter 
of the head at the outlet; (c) face presentations, in which the longest 
diameter of the fetal head presents; (d) either incomplete or excessive 
flexion; (e) faulty manual or instrumental interference. 

Degree or Extent. Lacerations of the pelvic floor may be incomplete or 
complete, and are generally divided into four degrees : first, a tear through 
the fourchet and to a slight extent in the perineum; second, to the sphinc- 
ter. These form the incomplete lacerations, while the complete are: 
third, the tear extending through the sphincter; and, fourth, up the rec- 
tovaginal septum. A rare form of laceration is the central rupture, in 
which the fetus passes through the perineum without tearing either the 
sphincter or the vulva. 



PERINEUM. 



267 



The results of the injury are necessarily dependent upon its extent. 
The immediate effects are induced by the action of the injured or antago- 
nistic muscles. The cicatricial tissue produces certain reflex nervous 
phenomena, which, however, are insignificant compared with the mental 
influence exerted by fecal incontinence. The laceration causes defective 
involution of the vagina and uterus, the defect in the muscular junction 
of the pelvic floor weakens the action and consequent resistance of the 
pelvic diaphragm. The constantly varying pressure of the bladder and 




2S0. 



Ivstocele. 



rectum; the increased abdominal pressure subsequent to straining at 
stool; and the abnormally heavy uterus lead gradually to displacement 
downward of that organ; or, if it is fixed by the condition of its pelvic 
attachments, to extrusion of the anterior and posterior walls of the vagina; 
and their consequent weight will produce hypertrophic elongation of the 
cervix. Thus we have cystocele (prolapse of the anterior vaginal wall, 
and with it the bladder), rectocele (prolapsed posterior wall), partial 
or complete prolapse of the vagina, with elongation of the cervix, or 
procidentia, attending the increased weight of subinvoluted organs and 
the diminished support resultant from the lesion under discussion. 



268 



GYNECOLOGY. 



Paradoxical as it may seem, the tendency to prolapsus uteri is not 
as marked in complete lacerations as when they are incomplete. The 
position of the anus and the resistance of the sphincter cause the rectum 
to be driven out between the levator ani muscles until considerable pro- 
trusion or rectocele occurs. The increased resistance with decreased 
support causes the anterior segment of the pelvic floor to project, forming 
a cystocele, and the traction leads either to prolapsus or to hypertrophic 
elongation of the cervix. 



1 



m^^^m': 



L_ 



pw»!aBiS 



Fig. 257. — Rectocele. 



Treatment. The proper course is so to repair the injury as to restore 
the normal condition of the pelvic floor as nearly as possible. In slight 
lacerations, restoration will be secured by keeping the patient quiet and 
the parts clean. The operative treatment may be primary, intermediate, 
or secondary. . 

By primary operation is understood the repair of the laceration 
immediately or at least within twelve hours. The tear presents a large, 
raw surface, and is found frequently with ragged, irregular edges. The 
vagina may have been torn and the soft parts pushed off until the peri- 



PERINEUM. 269 

neum has split either through the sphincter or to one or both sides of the 
anus. The method of repair will depend upon the nature and extent 
of the lesion. The necessary instruments will be found in an ordinary 
pocket case — scissors, dissecting forceps, a needle-holder, and long and 
short curved needles. The suture material may be silkworm gut, catgut, 
silk, or silver wire. The patient should be placed upon her back across 
the bed or upon a table, while an assistant holds each leg, flexed upon 
the abdomen. As the parts are benumbed by the stretching to which 
they have been subjected an anesthetic may be omitted; but if the 
patient is very nervous, one should be employed. A rubber pad or a 
piece of mackintosh should be placed beneath the patient to prevent 
soiling bed and to dhect the current of irrigating fluid into a receptacle 
upon the floor. Compress the uterus and cleanse it and the vagina of 
clots; cleanse the external surface with a disinfectant fluid, after having 
trimmed the vulvar hair in order to keep it from embarrassing the pro- 
cedure. Place a pad of gauze or absorbent cotton beneath the cervix 




Fig. 258. — Right and Left Curved Scissors. 

to keep the vagina free from blood. Trim smooth the ragged edges of 
the tear and proceed to suture. Fine chromicized catgut is preferable, 
because it will not have to be removed, and produces less annoyance dur- 
ing the care of the patient than does either silkworm gut or silver wire. 
In slight lacerations and vaginal tears the use of the continuous suture 
is satisfactory. In extensive laceration interrupted sutures offer advan- 
tages. Precautions should be exercised to leave no dead spaces in which 
blood may accumulate, become infected, and produce sepsis. In a 
double tear which extends upon both sides of the rectum the needle 
should be entered from above, brought out in the sulcus, reentered, and 
carried upward through the vaginal mucous membrane, so that each 
suture lifts up the tissue. Care should be exercised to restore the position 
of the levator ani muscles by bringing their torn ends back in position. 
So far as possible the sutures should be brought out in the vagina, as 
they thus produce less pain. The perineal edges of the tear may be 
united with a continuous catgut suture including but little of the skin. 

In laceration of the sphincter, make sure that the ends of the divided 
muscle are secured and coaptated by the suture. When the tear has 
extended into the rectovaginal septum, the sutures may be introduced 
and tied from the rectal side, or better, the Lauenstein suture with buried 
catgut may be employed. 



270 GYNECOLOGY. 

The advantages claimed for the primary procedure are: first, if the 
operation is successful, the patient is spared the necessity of a subsequent 
operation; second, with proper precautions, she is much less likely to 
suffer from infection, and convalescence is expedited; third, the sequelae 
of unrepaired injuries are avoided. 

Contraindications. The primary operation is contraindicated when 
the patient has been exposed to a prolonged labor and the tissues have 
undergone extensive fraying or bruising through prolonged manual or 
instrumental interference. It is also contraindicated when there is 
reason to believe that the wound has been exposed to virulent infection. 
In all cases of severe labor and extensive laceration of the pelvic floor, 
especially where there is reason to believe that there has been lacera- 
tion of the cervix, to some degree, I find myself in accord with those who 
advise deferring operative procedure for five to seven days. 

The intermediate operation may be performed from twenty-four hours 
to ten days subsequent to labor. The delay may be occasioned by the 
lack of proper material or the condition of the patient who is suffering 
from such profound shock that it will seem unwise to resort to any imme- 
diate procedure. Moreover, in severe cases it is better to be deliberate 
for at the end of five to seven days the involution of the uterus has occurred 
to such a degree as to permit recognition of injuries to the cervix; devital- 
ized tissues will be recognized by sloughing; and the absence of infection 
will be manifest. Should infection exist, this would of course delay opera- 
tive procedure still longer. 

The genital tract should be cleansed carefully, the raw surfaces wiped 
with a gauze sponge, any ragged surfaces trimmed, and the surfaces 
sutured as for the primary operation. 

Secondary operation is preferably not performed for at least two 
months after delivery in order to permit involution and cicatrization to 
become accomplished. In preparation, particularly when the tear is 
complete, the bowels must be thoroughly evacuated. Castor oil, a saline 
or compound licorice powder should be given several days or a week 
before the operation and repeated at intervals of from twenty-four to 
forty-eight hours, in order to insure thorough evacuation of all hard, 
scybalous masses. The diet should consist largely of animal broth, 
while milk should be absolutely excluded. The evening and morning 
before the operation the lower bowel should be cleansed with large enemas. 
The last enema should be given at least three hours before the time 
fixed for the operation. Patients should be prepared (Section 131), 
and the following instruments sterilized: a scalpel; right and left curved 
scissors, as well as scissors curved on the flat; three double tenacula; 
eight pressure forceps; one long, rat-toothed dissecting forceps; a needle- 
holder; and two long and two short curved needles, all threaded with 
carriers. The suture material may be silk, silkworm gut, catgut, or 
silver wire. In extensive laceration I formerly used silkworm but I 
now prefer chromic catgut for the reason that the different structures 
can be sutured separately and thus cause less tension on the superficial 
structures. This plan greatly relieves the pain and discomfort of the 



PERINEUM. 



271 



operation and relieves the patient from the annoyance caused by the 
removal of sutures. 

226. Operations on the Pelvic Floor. The aim of any operative 
procedure on the pelvic floor is to restore the parts to the normal relations 
or conditions as nearly as practicable. In many cases the laceration of 
the tissues has not been so great as the stretching of the posterior wall 
and the formation of the condition known as a rectocele which results 
from a diastasis, or separation of the levator ani muscles. This has 
been mentioned as more likely to occur in incomplete lacerations. The 
lesion leaves nothing to combat and overcome the resistance of the 





FiG._ 259.— Raising Flap for Perineal Oper- Fig. 260.— The Flap Raised, Exposing the 
ation, Exposing Diastosis of the Levator Levator Ani Muscles and the Sutures 

Am Muscle. Inserted to Draw in the ^luscles. 

sphincter ani muscle, and, as a consequence, the projection of the pos- 
terior vaginal wall— the rectocele— becomes more and more marked. 

The operative procedure to be effective must so reinforce the pelvic 
structures as to restrain this disposition of the posterior wall to eversion. 

The operative procedures devised for the restoration of the pelvic 
floor may be divided into three classes: i, denudation; 2, flap-splitting; 
and 3, muscular reconstruction. 

Only the desire to render this subject prominent justifies the last 
designation, for the operation can be made to supplement either of the 
other two and in my practice is used in a modification of the second almost 
entirely. 

Recognizing the importance of the levator ani muscles in the sup- 



272 



GYNECOLOGY. 



port of the outlet of the abdomen, it had been my custom for several years 
to utilize them by modifying the Emmet operation (to be described later) . 
By carrying the dissection through the fascia on either side of the vagina, 
exposing the edges of these muscles, and raising them by the introduction 
of futures, they were crowded in front of the intestine. In 1895, i^ marked 
cases of rectocele I removed a triangular section of the posterior vaginal 
wall, starting at the point of the beginning of the rupture on either side 
with its apex at the summit of the rectocele. Buried catgut sutures 





Fig. 261. — The Operation Completed. 



Fig 262. — Dissection for Complete Lacer- 
ation of the Pelvic Floor; Ends of the 
Sphincter Ani United; Suture Inserted to 
Bring Forward Levator Ani Muscles. 



were passed so as to pick up the levator ani on each side and crowd them 
forward in the median line, after which the mucous and skin edges were 
united by a continuous catgut suture. In 1906, I began to expose the 
muscles by dissecting up a flap similar to the method recently advocated 
by Barrett, and the union of the levator ani muscles, beneath it.^ The 
operation is done as follows: The patient lies on her back with the 
legs held in marked flexion by leg holders. The vulva is held open by an 
assistant, while I pick up the mucosa in the median line with tissue 



PERINEUM. 



273 



forceps, and cut through it with scissors in the lower margin of the 
vagina. This incision is carried laterally on either side to the border of 
the remains of the carunculae myrtiformes. Then, after loosening cica- 
tricial bands posteriorly, the flap thus formed is separated by blunt dis- 
section until the summit of the rectocele has been reached (Fig. 259). 
About the middle of this exposure a needle armed with a chromic catgut 
suture is passed deeply into the structure of the left levator ani, thence 
picks up the summit of the under surface of the flap, and out through 
the right levator. This suture drawn taut permits the muscles to be 




Fig. 263. — Dissection for the Restoration of a Complete Laceration of the Fourth Degree. 



picked up below and above by sutures. The upper suture picks up the 
center of the flap. Traction on the flap is discontinued and the sutures are 
'tied and cut close. (Fig. 260.) A suture now passed through the left angle 
of the dissection follows around the margin of the flap and is brought but at 
the right angle. This suture tied forms the posterior margin of the new 
vulva, while the remaining raw surface is closed by two or three inter- 
rupted sutures. (Fig. 261.) 

This, with a slight modification, serves well for complete laceration of 
the perineum of the first degree. The rectovaginal septum is split along 
or a little above its margin; the flap is carried forward as in the last 
procedure, and slightly backward to expose the ends of the torn sphincter 
muscle. These exposed ends are sutured with two or three catgut sutures, 



274 GYNECOLOGY. 

insuring their accurate apposition, when the levator ani muscles are 
united as in the preceding operation. (Fig. 262.) 

Where the tear extends up the rectovaginal septum, its margins should 
be split and rectal and vaginal flaps formed, after which the margins 
are sutured from the vagina side, making sure that the ends of the sphincter 
are secured. This line of sutures is covered by another row which brings 
forward the levatores, and finally the surface mucosa and skin can be 
united with either continuous or interrupted sutures. (Fig. 263.) These 
operative procedures have the following advantages: 



/ N 




Fig. 264. — Outline for Simpson's Operation. 

1. They preserve the tissue without loss. 

2. They insure the reinforcement of the pelvic floor by crowding in- 
ward the levator ani muscles, thus affording the greatest assurance against 
the reproduction of the vaginal hernia. 

3. The procedure is a simple one and requires the minimum of time 
for its performance. 

These operations are the evolution of principles so ably inculcated by 



PERINEUM. 



275 



Marcy, Simpson, and Tait, and adapted by Noble, Reed, Barrett, and 
others. 

The earliest flap operation on the perineum was that of Alexander 
Simpson. It was projected for the restoration of complete laceration. 
The flaps were outhned by splitting the rectovaginal septum and forming 
the anterior and posterior segments by incisions on either side at the 
junction of the skin and mucosa. The anterior flaps were united to 
form the posterior vaginal wall and the posterior, the anterior rectal. 
(Figs. 264 and 265.) 



\ 




Fig. 265. — Sutures Introduced in Simpson's Operation. 



The intervening raw surface is united with sutures to form the new 
perineum. 

The most representative operation of the flap procedures is that 
devised by Tait, differing somewhat in the incomplete and complete 
lacerations. 

In incomplete tears the rectum is tamponed with a sponge or with 
cotton or iodoform gauze covered with vaselin and furnished with a 
thread. While an assistant separates the vulva, two fingers are passed 



276 



GYNECOLOGY. 



into the rectum, rendering the posterior wall tense. To form the flap, 
Tait uses pointed angular scissors. The point of one blade is inserted 
in the median line at the mucocutaneous junction, and the rectovaginal 
septum is split to the depth of two centimeters, first to the left and then 
to the right, and is carried forward upon each side to the point at which 
he wishes the posterior commissure to be. (Figs. 266, 267, and 268.) 
This forms a semicircle following the mucocutaneous junction. The 
flap is drawn up by tenacula and further separated to the required depth. 
On the borders the incision is carried deeply into the cellular tissue of 







\mm 



Fig. 266. — Incision for Tait's Operation for Incomplete Laceration. 

the perineum and labium majus. Bleeding is controlled by forceps, 
and later by the pressure of the sutures. The sutures are passed with 
the fingers in the rectum as a guide. They pass transversely across 
the wound, the skin not being included. Four sutures are generally 
sufficient. The sutures are secured after the wound has been washed 
with sublimate solution (i : 1000) and the tampon has been removed. 

Sanger closes the skin edges with superficial sutures. 

In complete laceration the rectovaginal septum is split, forming a rectal 
and a vaginal flap, depending in extent upon the depth of the tear. 
Sanger advises that it be made with the bistoury. These flaps are loosened 



PERINEUM. 



277 



at either extremity by prolonging the incision upward just within the 
labia, and downward alongside the anus, thus forming a letter H, the 
transverse bar of which is formed by the split in the septum, and is at the 
lower part of the letter. These flaps, when separated, form a quadrilat- 
eral. Great care must be exercised in the introduction of the first suture, 
which must include the ends of the sphincter ani. 

Ristine of Knoxville, Tenn., in complete perineal operations outlines 
in the vagina the tissue which he considers as necessary to be denuded 
for the proper restoration of the pelvic floor and dissects this down as a 





Fig. 267. — Line of Incision for Tail's 
Operation for Complete Laceration. 



Fig. 



268. — A^jpearance of Surface after 
Formation of Flaps. 



flap which he utflizes after the closure of the wound in the protection of 
the newly united wound from infection by the contents of the rectum. 
The dissection exposes the divided ends of the sphincter muscle which 
are united with silkworm gut sutures. (Fig. 269 and Fig. 270.) After 
joining its edges with sutures, the flap is brought over the line of union to 
protect it from fecal infection. This flap can be clipped off at a later 
date after it has served its purpose, but it usually shrinks and gives no 
inconvenience. Noble, of Atlanta, accomplished the same purpose by 
loosening and drawing down the anterior wall of the rectum as a flap. 
Other operations in which flaps were formed and utilized were those of 



278 ^ GYNECOLOGY. 

Bischoff and Andrews. (Fig. 271, Bischoff's operation. Andrew's, 
Fig. 272.) Andrews retracted the flap behind the cervix. 

Fritsch's operation follows the principle of the Tait operation in the 
formation of flaps. He separates the vagina from the rectum and adds 
a lateral incision for the sphincter when its ends are retracted. The ends 
of the sphincter are held in place by a provisional suture which ensures 
the restoration of the normal shape of the orifice and permits the accom- 
plishment of the reunion. The rectum is restored by the Lauenstein 
suture of catgut. The same suture is employed to close the vagina while 





Fig. 269. — Outline of Flap to be Turned Down to Form Raw Surface for Union. Flap thus 
Formed to Protect from Fecal Infection. (Ristine.) 

the perineum is closed by superposed planes, or continuous catgut sutures 
in terraces can be used. (Fig. 275 and Fig. 276.) 

An operation devised by Alexander Duke may be classed with the 
flap operations. It is performed by passing the left index finger nearly 
its entire length, into the rectum; while, with a doubled-edge bistoury 
held in the right, the septum is penetrated a distance of six centimeters. 
(Fig. 277, 278, and 279.) 

As the lateral ends of the incision are pressed toward each other a 
lozenge-shaped opening appears. The sutures are introduced with a 



PERINEUM. 



279 



strong, sickle-shaped needle with eye in point, and silver wire is preferred 
for the suture. The needle is introduced just beyond the end of the 
incision, and guided by the finger into the rectum, is made to encircle 
the incision, to be brought out beyond its opposite end. Drawing up this 
suture will give an idea of the number of additional sutures required. 
The sutures secured, the distance between the anus and the posterior 
commissure is considerably increased, with the formation of a thick 
perineal body. 

The denudation of the torn vaginal outlet was the first method devised 




Fig. 



270. — Flap Turned Down. Sphincter Closed 
and Sutures Introduced. (Ristine.) 



Fig. 271. — Bischoff's Operation. 



for the restoration of the perineum which was then regarded as an exceed- 
ingly important structure. In the performance of the operation, as the 
cicatrization produced contraction, it is necessary to extend the denuda- 
tion of the vagina beyond the scar tissue. The extent and character of 
the denudation necessarily depends on whether the laceration is complete 
or incomplete. Incomplete laceration (Fig. 255) may be repaired by a 
simple denudation of the torn surfaces. (Fig. 280.) 

The line of denudation extends posteriorly from the junction of the 



28o 



GYNECOLOGY. 



mucous membrane and skin at the top of the old posterior commissure 
across in front of the anus to a corresponding point upon the opposite 
side, while an angle extends up the vagina above the tear. The com- 
pleted denudation presents a resemblance to the body and wings of the 
butterfly, and is designated the Simon-Hegar denudation. (Fig. 280.) 

The sutures are introduced about three millimeters from the margin 
of the wound, buried beneath the denuded surface, and brought out at 
a corresponding point upon the opposite surface. First the sutures in the 




Fig. 272. — Splitting Vaginal Wall Preparatory to Suture. (Andrews.) 



vaginal angle are secured, and then the perineal. (Fig. 281. )\ ,The 
sutures when tied produce less discomfort than if secured by compressing 
perforated shot upon their ends. The quill or bar suture was formerly 
much favored. It consisted of a quill placed in the loop of a double 
suture upon one side, the ends being tied over a second quill upon the 
opposite side; or the ends of a suture were passed through openings 
in a bar and secured by compressed shot. The two quills or bars served 
for all the sutures, while the skin edges were united by superficial sutures. 
The suture caused so much pain that it scarcely ever is used now. 



PERINEUM. 281 

A slight exaggeration of the denudation just described can be applied 
to the restoration of a complete laceration. The sutures must then be 
vaginal, rectal, and perineal. The latter are introduced after the former 
are placed. The rectal sutures of catgut are brought out into that canal. 
Care must be exercised in the introduction of the first perineal suture 
that it shall bring the ends of the sphincter ani in apposition accurately. 

Garrigues modified the Hegar operation by the following procedure 
(Fig. 282) : According to the extent of the laceration and relaxation of 




.^ 

*' -r 



Fig. 273. — Introduction of Suture in Retracted Flap. (Andrews.) 

the vagina and perineum the vagina is seized with a double tenaculum 
at a point in the median line more or less removed from the cervix. A 
point upon each labium majus is secured at such a distance from the clitoris 
as to permit of coition. The parts are rendered tense, the points are 
connected by an incision, and the intervening triangular surface is 
denuded. This denudation is carried downward to the margin of the 
skin and mucous membrane. With the vulva separated the denudation 
presents a triangular surface. 

The denudation is most rapidly accomplished by introducing one 
blade of curved scissors beneath the membrane at the point determined 
upon in the one labium and carrying it around the vaginal outlet to a 



282 



GYNECOLOGY. 



similar position opposite. The central part of this incision is picked 
up with forceps, cicatricial bands are cut, and the finger pushed beneath 
this flap to the desired height. The tissues are pushed off laterally, and 
the triangular section is removed. This has the advantage of being 
more than a denudation. It is a resection, and, therefore, permits the 
more accurate union of fascia and muscular structure. 

The sutures are introduced from above downward, about six milli- 
meters apart, deep and superficial alternating, the latter passing only 





^ 




Fig. 274. — Suture Tied; the Remaining 
Surface to be Closed by Transverse 

Sutures. (Andrews.) 



Fig. 275. — Denudation tor Pritsch's 
Operation. 



through the edges of the mucous membrane. The four upper sutures 
are transverse; the remainder dip downward at the central portion, and, 
when tied, lift up the relaxed wall. The sutures are thus introduced and 
tied one after another until the remaining denuded surface forms an 
ellipse, the upper and lower borders of which are of equal length. (Fig. 
283:) Then a silkworm gut suture (10) one centimeter above the 
posterior commissure is carried deeply beneath the wound two-thirds 
the width of the denudation, and emerges at a similar point upon the 
opposite side. A second suture (11) is inserted midway between this 



PERINEUM. 



283 





^^- 



"T 




FiG. 276. — Catgut Sutures for Union of 
The Rectal Wall. 



Fig. 277. — Incision for Duke's Operation. 




Fig. 278. — Incision Separated in Vertica 
Direction. 



Fig. 279. — Incision United by Trans- 
verse Sutures. 



284 



GYNECOLOGY. 



suture and the outer margin; passing beneath the denuded surface it 
emerges upon the vagina to the left of the median Hne, is reintroduced, 
and comes out equally distant from the first suture upon the right side. 
The last suture, introduced near the extremity of the denuded surface, 
appears in the vagina midway between the second suture and the ex- 
ternal denuded angle, reenters upon the opposite side, and emerges upon 
the right labium. These three sutures are all introduced and the surface 
is irrigated, then they are secured. (Fig. 284.) 

The employment of the continuous chromic catgut suture would 
seem more satisfactory. It can be so introduced as to lift up the pelvic 





Fig. 280. 



-Simon-Hegar Method of 
Denudation. 



Fig. 281. — Sutures Introduced to Close 
the Wound. 



floor, and include the edges of the levator ani muscle and the overlying 
fascia. If the floor is much relaxed, the muscle and fascia can be sutured 
separately and the mucous surfaces be closed over it with a continuous 
suture. This method greatly expedites the operation and has the advan- 
tage that it leaves no sutures (Fig. 291) to be removed. 

Lauenstein's method of introducing the sutures was devised to prevent 
their infection by rectal and vaginal discharges. The sutures, of catgut 
or fine silk, are introduced in the denuded surfaces, including about five 
millimeters of the tissue intervening between the borders of the rectal 



PERINEUM. 



285 



and vaginal mucous membranes respectively. (Fig. 285.) These are 
necessarily buried sutures. The remaining portion of the denuded sur- 
face is closed by silver wire from the perineum. (Fig. 286.) 

Hildebrandt makes the denudation trefoil in shape. (Fig. 287.) 
The sutures are, for the most part, cutaneous. The vaginal sutures are 
first introduced; next the rectal, and, finally, the perineal. (Fig. 288.) 
This method of suturing obliterates dead space and decreases the danger 
of abscess. 




Fig. 282. — Garrigues' Modification of the Hegar Operation. 



Heppner accomplishes the same object with a figure-of-8 suture, 
which closes both vaginal and perineal surfaces. (Fig. 289.) 

Martin more rapidly, and with a less complicated procedure, meets 
the difficulty. (Fig. 290.) With a continuous catgut suture, he unites 
the intestinal wound from the rectal surface; when he reaches the anus, 
with the same suture in a contrary direction he superimposes a layer 
up to the superior angle of the vagina, and, if the denudation is deep, a 
third layer before the vaginal and perineal surfaces are united. (Fig. 
291.) 



286 



GYNECOLOGY. 



Freund has emphasized the necessity of securing such a denudation 
as would reproduce the original appearance of the tear. This, if there 
is a cicatrix, which presents the appearance of oo, the laceration from which 
it has contracted may be represented by figure 292. He incises the posterior 
column of the vagina at a certain distance from the scar and carries 
the bistoury backward along the sides of this column, circumscribing 
the cicatrix in the vagina and upon the labia majora (Figs. 293, 294, and 
295), and completes the denudation as in an ordinary operation. The 
line which corresponds to the rectum is sutured, then each edge of the 





Fig. 283. — Upper Part of Wound Closed; 
Last Sutures Introduced. 



Fig. 284. — Wound Completely Closed. 



posterior vaginal column is united to the external margin of the denuded 
surface. The union of the lines forms the vulvar and perineal surfaces. 

Of the denudation operations, that of Emmet without question 
takes the first place. Its purpose is to expose the fascia and so introduce 
the sutures as to fold in the slack and lift up the perineum and bring it 
more under the control of the levator ani muscles. 

More fully than any preceding measure, the operation devised by 
Emmet supplied the support required for the tendency to prolapse of 
the posterior vaginal wall, in the incomplete lacerations of the pel- 



PERINEUM. 



287 



vie floor. He constructed a quadrilateral denudation upon the posterior 
aspect of the vulva and vagina by fixing with tenacula the remnants of 
the hymen, the caruncula on each side of the vagina, the margin of the 
cicatricial tissue posterior, and the summit of the rectocele above. With 
these points separated, the intervening mucosa was removed. The 
sutures introduced from the vaginal surface formed a double tri- 
angle (Fig. 296) and when tied lifted the levator ani and its fascia. 
The next suture unites the labia with the point of the denudation 





Fig. 



-Lauenstein Suture. 



Fig. 286. — Rectum and Vagina Closed 
with Lauenstein Suture. 



in the vagina. It is known as the crown stitch and forms the subsequent 
posterior commissure of the vagina. The raw surface beneath it is 
united with sutures. (Fig. 297.) (Emmet's operation. Lateral angles 
closed and crown stitch introduced.) (Fig. 298.) The majority of the 
sutures is in the vagina and the posterior segment of the pelvic floor is 
brought more closely in contact with the anterior. 

Noble modifies this operation by carrying his denudation higher upon 
the posterior column, splitting the fascia, and exposing the levator ani 
muscles. In suturing, he pulls out the muscle and secures it with not 



288 



GYNECOLOGY. 




Fig. 287.— Hildebrandt's Method of Suturing. 



PERINEUM. 



289 




Fig. 288.— Hildebrandt Suture Closed. 





Fig. 289. — ^Heppner's Figure-of-8 Suture. FiG. 290. — Martin Suture to Close the 

Rectal Opening. 

19 



290 



GYNECOLOGY. 



only the lateral, but also the central, sutures, or those below the crown 
suture. This brings the muscles in contact in front of the rectum and 
insures a strong support to the pelvic floor. 

Emmet's operation for complete laceration has for its first and princi- 
pal aim the restoration of the sphincter ani. The first suture is introduced 
and brought behind the ends of the torn sphincter, which have been care- 
fully exposed in the denudation. (Figs. 299 and 300.) As the suture 
is drawn up and secured the precaution is taken to draw up and place 





Fig. 291. — Martin Suture Continued. 



Fig. 292. 



-Denudation for Freund's 
Operation. 



in position the ends of the sphincter, so that they may be secured firmly. 
The remaining sutures appose the denuded surface of the perineum. 
Outerbridge modifies Emmet's operation in that he uses but three 
sutures. The first, of medium-sized catgut, by means of a needle threaded 
with a carrier loop, is passed from the end of the central undenuded 
portion to the summit of the lateral denudation upon either side. It is 
thrown over the pubes and a silver-wire suture is passed from the highest 
point of the denudation upon one labium majus beneath the whole 
wound across to the corresponding point upon the opposite side. (Fig. 



PERINEUM. 



291 




Fig. 293. — Sutures Inserted in Rectal Wall and Lateral Vaginal Angles. 




Fig. 294. — ^Vaginal Angles and Rectal 
Wall Closed. Suture in Place for 
Perineum. 




Fig, 295. — Denudation Completely 
Closed. 



292 



GYNECOLOGY. 



301.) The catgut suture is now tied and its ends are passed downward 
to penetrate the skin upon each side one centimeter from the lowest point 
of the denudation. This suture tied, the silver wire is secured. The 
latter suture is removed upon the eighth day. 

Cleveland uses a figure-of-8 suture of catgut. (Fig. 302.) The 
first suture enters the skin six millimeters from the wound margin and 
midway between the posterior commissure and the summit of the denuda- 
tion in the left labium, passes deeply across between the denuded surfaces 




Fig. 296. — Emmet's Operation. Surface 
Denuded and Lateral Sutures in Place. 



Fig. 297. — Emmet's Operation. Lateral 
Angles Closed and Perineal Suture Intro- 
duced. 



and rectum, embracing the muscles, and emerges upon the right labium 
six millimeters from the wound margin. Midway between the posterior 
commissure and the point corresponding to its entrance, the suture is 
reintroduced at a similar point upon the left labium, and emerges upon 
the right, directly opposite its original entrance. 

The second suture follows a similar course. It enters the left labium 
near the summit of denudation, is buried beneath the edge of the denuda- 
tion to the center of the vaginal column, then passes downward, and 



PERINEUM. 



293 




I 
Fig. 298. — Emmet's Operation Completed. 




Fig. 299. — Emmet's Operation for Com- 
plete Laceration. 




Fig. 300. — Suture to Unite the Ends of the Sphincter. 



294 



GYNECOLOGY. 




Fig. 301. — Outerbridge's Suture. 



PERINEUM. 



295 



emerges upon the right labium midway between the summit of denuda- 
tion and the exit of the first suture. It is introduced upon the left labium 
at a corresponding point, passes across its former course, follows the 
border of the right sulcus, and emerges beneath the right summit. 

A suture of wire or silkworm gut, for support, is passed through the 
left labium, about eight millimeters above the denudation, and about 
the same in the anterior vagina and the right labium. 

A. P. Dudley made a quadrilateral denundation with angles at the 
summit of the rectocele, laterally at the caruncula, and at the posterior 
commissure. The denudation removes only the mucous layer, preserv- 




FiG. 302. — Cleveland's Suture. 

ing the submucous. (Figs. 303 and 304.) The finger is introduced into 
the anus and the first suture is passed downward and forward to the 
median line, where it is brought out, reintroduced three millimeters from 
its exit, and carried upward and backward to emerge upon the other side 
of the vagina. This suture is tied, and acts as a fixed point from which 
to work. The remaining sutures, of juniper catgut, are made over 
and over and are introduced in a direction similar to the first, taking care 
to push up the rectocele with a director as each stitch is tightened. As 
the outlet is approached the angle of the sutures is decreased, until, 
when abreast of the hymen, they are passed transversely. At this point 
the inside work is finished and the suture is made fast. A number of 
buried sutures are passed through the fibers of the separated central 



296 



GYNECOLOGY. 



tendon. These extend to the extremity of the rent, when, with a continu- 
ous suture, they return to the point where the deep sutures began. After 
examination of the wound for bleeding points or gaping of the surfaces 
the wound is dusted with iodoform, and is not disturbed for four days. 
Martin, in extensive relaxation of the pelvic floor, supplements the 
operation upon the vulvar outlet by a denudation of the lateral columns 
of the vagina, leaving a tongue-shaped, undenuded strip in the median 
line of the vagina. (Figs. 305 and 306.) Each lateral denudation is 
obliterated by continuous suture, after which the outlet is closed with 
transverse sutures. (Fig. 306.) 






Fig. 



303.- — Dudley's Operation with 
Interrupted Sutures. 



Fig. 304. — Dudley's Operation 
Completed. 



Choice of Operation. It should be understood that no operation is 
applicable to every patient. The operation should be adapted to the 
special condition. The flap-raising procedure with union of the muscles 
by buried catgut sutures comes nearer to being applicable to all condi- 
tions than any other. For complete laceration the first consideration 
must be the restoration of the sphincter, and this is most effectively 
accomplished by union of the divided ends by buried catgut sutures 
after which the levator ani muscles are united over the sphincter. The 
vaginal walls are unlikely to be prolapsed in complete lacerations. 



PERINEUM. 



297 



After-treatment. Immediately after operation cleanse the vulva 
with alcohol and water, equal parts, dry and apply a sterile gauze pad 
which should be retained by a T-bandage. The nurse should be 
directed to sponge the parts with the same solution, whenever soiled 
The patient is unlikely to suffer pain, unless the laceration has been 
complete, when a suppository of opium extract, gr. j, and hyoscyamus 
extract gr. ss, can be administered. The urine should be evacuated 
spontaneously and the parts subsequently sponged. The position of 





Fig. 305. — Denudation for Martin's 
Operation. 



Fig. 



306. — ^Vaginal Surfaces United: 
Perineal Sutures in Place. 



the patient may be changed, but she should be discouraged from making 
severe efforts. In incomplete lacerations the diet will not require careful 
scrutiny, but in the complete it should be limited during the first week 
to animal broths, and for another week to articles that are easily digested. 
Secure an evacuation of the bowels upon the third day, and at least each 
alternate day subsequently. Exercise care that excessive purgation does 
not occur. The sutures, if of silk or silkworm gut, can be removed in 
eight days to two weeks. Catgut sutures need not be disturbed. Ob- 
serve care in the removal of the sutures; the patient is preferably placed 
upon her side before a good light, and an assistant, by gently separating 
the buttocks, exposes the ends of the sutures, and facilitates their with- 



298 GYNECOLOGY. 

drawal. Keep the patient in bed three full weeks. After the fourth 
day the vagina may be irrigated once or twice daily with a disinfectant 
solution — sublimate (i : 2000) or formalin (i : 1500). Advise her to do but 
little walking for a month, and interdict coition for two months. 

INFLAMMATIONS. 

227. Recognition of the development of the genital tract from 
the coalescence of the Miillerian ducts makes evident that it is a continu- 
ous canal which must be especially vulnerable to infection with its mani- 
festation, inflammation. 

Experience discloses that the alterations due to infection are rarely 
confined to a single portion of this tract, although the special structure 
of certain portions of the canal renders them more susceptible to the 
influence of micro-organisms. The cylindric epithelium of the cervical 
canal is more vulnerable to gonorrheal infection than the pavement 
epithelium lining the vagina. The recognition of the almost continuous 
uniformity with which the different parts of the canal become involved 
from the structure primarily infected, and the frequent difficulty in 
isolating the primary site have caused me to depart from the usual 
order in the consideration of this subject, and to discuss infection and 
the resulting inflammation as affecting the entire genito-urinary tract, 
and subsequently to consider the features of its local manifestations. 

228. Micro-organisms are the most important exciting cause in the 
production of inflammation of the genito-urinary tract. Inoculation of 
a mucous surface with a micro-organism may result in an immediate 
inflammatory reaction, which may extend subsequently to the neighbor- 
ing structures by one of three ways : the mucous membrane, the lymphatics, 
or the blood-vessels. The original site of inoculation may be the vulva, 
vagina, uterus, urethra, or the bladder surfaces, as these are more or 
less exposed to external contact. Even the entire tract may be involved. 

The situation of the genital tract, the injuries to which it is exposed, 
and the opportunities for its infection by various germs render the com- 
paratively infrequent occurrence of inflammatory attacks surprising. 
Immunity against infection is to some degree due to the difference in the 
character of the uterine and vaginal secretions. It will be remembered 
that the uterine secretion is alkaline, while that of the vagina is acid; 
consequently micro-organisms which would readily flourish in the one 
canal are unfitted for invasion of the other. 

Any condition, then, which causes these secretions to be less antago- 
nistic, or which leads the one to preponderate greatly, permits the activity 
of the germs and their products to become manifest. Lowered vitality, 
exposure to cold, menstruation, the increased flow incident to parturition 
or abortion, all render the secretion more alkaline and establish a more 
uniform soil for the development of micro-organisms. Apparently condi- 
tions which appear normal may be overcome at once when the tract has 
been inoculated with some virulent poison. 

229. Inflammation has been defined as an expression of the effort 



INFLAMMATIONS. 299 

made by a given organism to rid itself of, or to render inert, noxious 
irritants arising from within or introduced from without. Inflamma- 
tion may be acute or chronic, diffuse or circumscribed. It is acute 
when associated with pain, heat, burning, more or less swelling of the 
tissues, profuse discharge, and constitutional symptoms. It is chronic 
when the condition is somewhat protracted; the pain less severe or slight; 
the discharge less in amount and less irritating to the surrounding struc- 
ture, and with slight constitutional reaction. Diffuse inflammation may 
involve the entire genital tract, as in streptococcic or gonococcic infection, 
either of which may extend the entire length of the genital canal, involv- 
ing vulva, vagina, uterus, and tubes, and even the ovaries, peritoneum, 
and cellular tissue. The latter form of infection may invade the urinary 
tract simultaneously, but circumscribed or local irritation confined to a por- 
tion of the tract is much more common. 

The causes of inflammation should be divided into predisposing and 
exciting. The predisposing causes are those which produce congestion 
and disturbance of the normal equilibrium of the tract and, consequently, 
promote a favorable condition for the inception of infection. Such are 
derangements of the internal secretions which either lessen the flow 
or render it excessive or irregular. They are caused by disturbances 
of menstruation, involution, or the occurrence of traumatism. The 
first includes the improper hygiene of menstruation, exposure to 
cold, fatigue, overexercise, and excessive sexual relation during the con- 
gestion immediately preceding or following menstruation, a cold bath 
taken to prevent menstruation, or neglect or imprudence following abortion, 
miscarriage, or parturition. The natural congestion following these 
periods is enhanced by exposure, permits infection by various micro- 
organisms, with the resultant interference of the normal physiologic 
results in inflammation, interference with the normal processes, and the 
subsequent development of inflammatory changes. Uncleanliness or 
want of care upon the part of physician or nurse in a manipulation during 
or following labor or an abortion, or in the use of the uterine or vaginal 
douche; upon the part of the patient in handling the parts with unclean 
hands; the act of masturbation; the employment of unclean instruments; 
the retention within the uterus or vagina of portions of placenta, decidua, 
or bloodclots following abortion or labor; the presence of foreign bodies, 
such as tampons, tents, stem pessaries, especially soft rubber pessaries, 
which are prone to become foul, can be properly considered as causes. 
Traumatisms, including lacerations of the perineum, vagina, and cervix, 
the unskilful management of abortion or parturition, rough or unskilful 
examination, careless use of the sound or intra-uterine manipulation 
without asepsis, and excessive or violent coition, are also contributing 
factors. Chemic and vegetable poisons, such as phosphorus and the 
essential oils, may cause acute metritis. A patient suffering with chronic 
inflammation may have acute attacks which are excited by overexertion, 
sexual excess, operations, or rough examinations. Inflammation may 
be promoted by the presence of uterine displacements, pelvic or uterine 
tumors, or profuse inflammatory exudates or morbid processes. The 



300 GYNECOLOGY. 

exciting causes are the pathogenic micro-organisms and their products. 
They are the gonococcus, the streptococcus pyogenes, the staphylococcus 
pyogenes aureus and albus, the bacillus coli communis, the bacillus 
tuberculosis, and the saprophytes from the bladder, rectum, and colon. 

Inflammation of the vulva and vagina can be produced by the passage 
through them of a septic discharge from a sloughing fibroid, by malignant 
disease of the cervix or uterine body, by the contents of a pelvic abscess 
or pus-tube, or by being constantly bathed with feces or urine escaping 
through fistulse. Of the various micro-organisms that of gonorrhea 
is the most prolific cause of disease. In woman gonorrhea is far more 
dangerous than syphilis, for when infection enters the genito-urinary 
canal, the entire tract may become involved and she may suffer from 
chronic inflammation of the uterus, suppuration of the tubes, inflamma- 
tion of the peritoneum and ovaries, as well as cystitis, ureteritis, and in- 
flammation of the pelves of the kidneys. Not only does she lose her power 
of reproduction, through its influence, but she develops inflammatory 
conditions, which, if they do not effect a fatal termination cause such 
destructive changes in the pelvic organs as to necessitate their removal 
in order to prolong life or render it endurable. While the recurrence of 
gonorrhea may not in all cases cause sterility, its existence renders the 
soil favorable for the development of sepsis subsequent to abortion, par- 
turition, or rough and unskilful manipulation. Careless examination, 
the introduction of the sound, and other intra-uterine manipulation 
without thorough asepsis are too frequently the causes of the renewal 
and extension of serious pelvic inflammation. 

Acute exacerbations are readily produced by overexertion, fatigue, 
cold, or rough manipulation when the pelvic organs are the seat of chronic 
inflammation. 

Characteristics of Inflammation. It should be well understood that 
inflammation, in the great majority of cases, is primarily a product of 
infection, and, consequently, is not necessarily to be regarded as a rep- 
rehensible process, but, on the contrary, as an effort to guard and pre- 
serve vital structures from injury and invasion. Its first aim, then, is 
defensive; the second, constructive and reparative. These processes 
are often so intermingled as to render differentiation difficult. 

The defensive element is more marked in the acute process, and is 
associated with proliferation, degeneration, and destruction, dependent 
in degree upon the virulence of the infection and the capabilities of re- 
sistance. Efforts are set in operation to establish a retaining wall. 
Blood stasis, cell proliferation, and exudation occur; degeneration and 
destruction follow. Such a process causes pain, a burning sensation, 
elevation of temperature, extreme sensitiveness, swelling, and more or 
less constitutional reaction. The process may terminate in resolution or 
go on to suppuration. 

Acute and chronic inflammations are ofttimes mere stages in the in- 
fective process, and the one insensibly fades into the other. In the latter, 
defensive action is slight and not marked by an extensive hmiting wall. 
Naturally, the symptoms are less severe, and, as the constructive ele- 



INFLAMMATIONS. 3OI 

ments predominate, as seen in hyperplastic conditions, the neuropathic 
disturbances are more marked. 

The inflammatory process may begin with a chill, or with repeated 
rigors, associated with elevation of temperature and with tenderness 
over the pelvic organs. This is often so great as to render the contact 
of the clothing or bed-clothes quite unendurable, especially when the 
peritoneum has become involved. Increased secretion and discharge 
is an invariable symptom, necessarily dependent upon the seat and charac- 
ter of the inflammation. Disturbance of the functions of the genital 
organs also occurs necessarily. In acute attacks the organs are so sen- 
sitive that a digital examination is frequently attended with agonizing 
pain. 

The menses may be arrested (amenorrhea) or greatly aggravated 
(menorrhagia) , while not infrequently there is profuse irregular bleeding 
(metrorrhagia). Increased or irregular flow is more likely to be associ- 
ated with involvement of the peritoneum and cellular tissues, because the 
resulting exudate obstructs the pelvic venous circulation. The bleed- 
ing occasionally is internal. More frequently, however, there is a trans- 
udation of serum and plasma into the cellular tissues, which forms the 
condition known as parametritis or pelvic ceUulitis. 

230. Classification. Frequently inflammation will begin in one 
portion and rapidly involve the structures of the entire genito-urinary 
tract; therefore it is difficult to specify any particular organ as its primary 
site. Furthermore, in other cases the virulence of the micro-organisms 
may be so great and the defensive power of the patient so slight that 
general infection takes place, and localization, if it occurs, may be in organs 
remote from the site of original infection. The gonococcus is an example 
of the former, while infection with the streptococcus illustrates the latter. 
In the majority of cases inflammation preponderates in a portion of the 
genital canal or pelvic structure, and is named for the part mostly affected. 

Inflammation of the vulva, vulvitis. 

" ducts and glands of Bartholin, Bartholinitis. 

" urethra, urethritis. 

" bladder cystitis. 

" vagina, vaginitis. 

" uterus, metritis. 

" tubes, salpingitis. 

" ovaries, ovaritis or oophoritis 

A Still more minute classification of inflammation is made in relation 
to the particular structure or portion of the organ involved, as the mucous 
membrane, the muscular structure, or the periphery. Thus, with the 
vagina we may have an endovaginitis, a parenchymatous vaginitis, and 
a peripheral or perivaginitis. The uterus furnishes an endometritis, 
a parenchymatous metritis, a perimetritis, the last involving the peritoneal 
covering, and an inflammation of the cellular tissue, known as para- 
metritis or, better, pelvic cellulitis. The tube is affected by endosalpin- 
gitis, parenchymatous salpingitis, and perisalpingitis. Inflammation 
of the serous covering of the uterus is perimetritis. It is, however, rare 



302 GYNECOLOGY. 

to find this portion of the peritoneum alone involved. More frequently, 
the entire pelvic peritoneum, including that of the uterus, broad liga- 
ments, and tubes, is inflamed, so that the term pelvic peritonitis affords 
a more accurate description. Inflammation of the pelvic peritoneum 
rarely occurs without more or less inflammation of the cellular tissue. 
It cannot be denied that we may have cellular inflammation without 
very extensive involvement of the enveloping peritoneum. When this 
occurs, it is known as pelvic cellulitis, 

231. Vulvitis (inflammation of the vulva), varies in degree from 
a slight erythema to a very severe and destructive involvement which 
may result in the formation of an extensive abscess, or in the destruction 
of a large portion of the labium. It is usually divided into simple or 
catarrhal, follicular, venereal, eruptive, phlegmonous, and diphtheric. 

Causes, Vulvitis is generally produced by infection. Its develop- 
ment is favored by neglect of cleanliness. The decomposition of the 
sebaceous and sudoriferous glandular secretion, which, with desquamated 
epithelium forms the smegma, accumulates between the labia majora and 
labia minora and beneath the prepuce of the clitoris, will often cause an 
attack of inflammation similar to balanitis in the uncleanly male. In 
obese women the decomposing perspiration, mixed with vaginal secre- 
tions will keep the surfaces constantly irritated and produce an extremely 
offensive odor. 

The tendency to inflammation is enhanced by the gouty, rheu- 
matic, and scrofulous diatheses, and by intemperance in eating and 
especially drinking. Vulvitis is often produced by uterine and vaginal 
discharge, from malignant disease, or from pelvic abscesses which have 
opened into the vagina. 

The continual soiling of the vulva with the urinary and fecal discharge 
associated with fistulae is productive of vulvar inflammation and often 
erosion of the surfaces. Vulvitis is excited and aggravated by mastur- 
bation and excessive coition, and by pruritus accompanying the presence 
of pin-worms, ants, and pediculi. The various eruptive diseases, as 
eczema, herpes, acne, furuncle, warts, and venereal sores, are productive 
causes. A severe form of vulvitis is generally associated with eczema, 
and intense pruritus is caused by the presence of the torulae cerevisiae in 
diabetic urine. Inspection will reveal whitish tufts over the surface, 
which arise from the spores of the oidium albicans. Severe vulvitis 
with eczema should always lead to examination of the urine in order to 
exclude the presence of sugar. Vulvitis is a frequent complication in the 
eruptive and infectious diseases of childhood, such as scarlatina and diph- 
theria. It may arise from the extension of inflammation from the anus or 
bladder. 

Simple or Catarrhal Vulvitis. In the acute stage of vulvitis the labia 
minora, the clitoris, and the fourchet are swollen and thickened. The 
parts are red, angry, and dry. Later, they are covered with a profuse 
purulent discharge of an extremely offensive odor. This discharge is 
produced by an increased secretion from the sebaceous glands mixed with 
desquamated epithelium and pus-corpuscles. 



INFLAMMATIONS. 



303 



Pruritus, as in all forms of vulvar inflammation, is a marked symptom, 
and is at times so severe as to prevent sleeping and force the patient to 
abjure society. The temptation to scratch or rub the parts becomes 
almost irresistible. The contact of the urine causes smarting or burning. 
As the disease becomes chronic, the surface is not so bright a red; it be- 
comes a,braded; at points, small ulcers form, the skin is greatly thickened, 
the papillae become hypertrophied, bleed easily, and are red; often the 
surface presents points of excoriation, which extend upon the vulva into 




Fig. 307. — Follicular Vulvitis. 

the groins and the inside of the thighs, when the itching is intolerable. 
The glands in the groin often become swollen, and may even undergo 
suppuration. 

In follicular vulvitis inflammation is limited to the hair-follicles or 
originates in the sudoriferous and sebaceous glands. (Fig. 307.) The 
surface of the vulva is studded with small round protuberances the size 
of a millet-seed or hemp-seed. These elevations begin as papules, 
which may suppurate, forming pustules, which burst and shrivel, or they 
may remain as small indurations. The intervening skin is unaffected. 

Venereal vulvitis is produced by gonorrhea, syphilis, and chan- 



304 GYNECOLOGY. 

croid. The former is the most prohfic source. Gonorrheal vulvitis is 
much more intense than the catarrhal. It involves particularly the 
vestibule and smaller labia. The latter are very red and edematous, 
while the external meatus of the urethra and the orifices of the ducts of 
Bartholin are generally red and swollen. Small excoriations which 
bleed easily occur frequently. The disease is attended with a profuse 
purulent secretion, in which the gonococcus is found. The microscope 
shows the subepithelial tissue to be exceedingly vascular and infiltrated 
with solid groups of round cells. The epithelium will be seen in varying 
stages of granular degeneration and desquamation. Gonococci pene- 
trate the epithelium and are found in the underlying tissues. The inflam- 
mation extends to the vagina, not infrequently through the urethra to 
the bladder. Often Bartholin's glands are inflamed, occasionally result- 
ing in abscess formation. Micturition is followed by intense burning. 

Vulvitis due to syphilis occurs in the form of a single sore with 
indurated base and excavated surface, which is situated upon the large 
or small labium or in the neighborhood of the clitoris. In the secondary 
stage there are mucous patches similar to those found in the mouth. 

Chancroids produce a more or less extensive ulceration, generally in- 
volving adjoining surfaces. Syphilis causes indurated enlargement of the 
inguinal lymphatic glands, while chancroid is characterized by their 
inflammation and suppuration, causing the condition known as buboes. 

232. Eruptive Diseases of the Vulva. Skin diseases manifest the 
same characteristics when situated upon the vulva as in other portions 
of the body. The most important, because the most frequent, are ec- 
zema, erysipelas, and herpes. 

Eczema generally begins upon the labium majus or upon the mons 
veneris, from which it extends to the thighs, perineum, anus, and over 
the buttocks. In the acute stage the surface becomes red and swollen, 
burns, and is covered with transparent vesicles the size of a pinhead. 
It is associated with fever, gastric irritation, and rheumatic symptoms, 
and becomes chronic by the end of the second week. Chronic eczema 
generally appears in the form of eczema rubrum, and the surface is cov- 
ered with pus, dry scales, or crusts. Fissures form at the fourchet and 
anus and in the genitocrural folds. All the symptoms are greatly ag- 
gravated at the menstrual periods. Pruritus is intolerable. The oc- 
currence of eczema of the vulva is generally associated with the appear- 
ance of the disease upon other parts of the body. It is a frequent 
consequence of diabetes mellitus, owing to the irritation of the sugar- 
containing urine. It is also an outcome of the rheumatic diathesis. 

Erysipelas may occur as a primary affection of the vulva in the new- 
born, when it is a very serious disease, frequently proving fatal. It 
occasionally occurs periodically with the catamenia, or may even take 
the place of the latter. Its occurrence during the puerperal state is gen- 
erally an indication of serious infection. 

Herpes manifests itself by the appearance of small transparent vesicles, 
from the size of a pinhead to that of a pea, which may be few or multiple, 
discrete or confluent; rarely, as a single erosion of large extent. The 



INFLAMMATIONS. 305 

advent of the disease is characterized by heat, smarting, and an area of 
redness, which is covered with agminated vesicles. These vesicles may 
fuse and form a large bulla. The vesicles dry; the edges of an ulcer are 
scalloped and its surface is covered with a crust, beneath which cicatriza- 
tion is completed within from eight to fifteen days. The inguinal glands 
are engorged and painful, but do not suppurate. 

Causes. Accidental herpes may be caused by syphilis, gonorrhea, 
filth, and constitutional conditions. Congestion is a predisposing cause. 
In some women it occurs each month two days in advance of menstrua- 
tion; also during pregnancy. 

Phlegmonous inflammation of the tissues may result from the catarrhal 
inflammation or may be the result of violence. It affects the deeper 
structures and subcutaneous tissues, resulting in serpiginous ulceration, 
which may form a permanent fistulous tract, or the inflammatory area 
may be so extensive as to cause the formation of an abscess. 

Diphtheria may, but rarely does, affect the vulvar mucous membrane. 
The so-called diphtheric vulvitis is an exudation found upon lesions of 
the vulva and vagina, produced by parturition, and is the result of septic 
infection; Such exudations are found also in grave constitutional dis- 
orders, such as scarlatina, smallpox, and typhoid fever. 

In a woman whom I saw prior to death from sepsis subsequent to 
the delivery of an intra-uterine sessile fibroid, the vulva, vagina, and 
uterus were lined with a diphtheric exudate. 

Diagnosis, especially the differential diagnosis, of the inflammatory 
disorders of the vulva is of great practical importance. Gonorrheal vul- 
vitis is evident from the greater intensity of its symptoms. It is character- 
ized by an increased burning during micturition, profuse purulent dis- 
charge, and redness of the meatus and orifices of the ducts of Bartholin. 
It has a tendency to extend to the tubes, ovaries, and peritoneum, as 
well as an increased inclination to involve the urinary tract. Its recogni- 
tion is rendered certain by the discovery of the gonococcus, and the 
known fact of exposure to the virus. The absence of the gonococcus is 
not proof positive against the specific character of the disease, as the 
germ may have disappeared. Late investigations seem to show that 
the gonococcus is capable of assuming amorphous forms and resuming 
its original form and virulence under irritation. Thus are explained 
the recurrences of the disease after a debauch, excessive venery, or ex- 
posure to cold in individuals apparently cured. 

Vulvitis in the virgin from masturbation is suspected when the smaller 
labia and the space between them and the hymen are covered with 
small, pointed excrescences; the nymphae are elongated; the clitoris or its 
prepuce is irritated; swelling of the shallow groove between the orifice 
of the urethra and the clitoris exists; clear, abundant secretion from the 
ducts of Bartholin occurs; and associated with these phenomena there 
is abnormal sensibility; exaggerated prudery; and distinct hysteric symp- 
toms. Discontinuance of masturbation may be assumed when the 
hypertrophied nymphae become soft and no longer show any indication 
of inflammation. 



306 GYNECOLOGY. 

Eczema can be recognized by the similarity of its symptoms to those 
of the disease when it occurs in other portions of the body. If the sur- 
faces are covered with whitish tufts, this should arouse suspicion of the 
presence of torulae cerevisise, which is revealed by the microscope, and 
the presence of sugar in the urine. The urine should be examined in 
every case of eczema of the vulva. Herpes is frequently confounded 
with chancroid from which it is distinguished by its early history. The 
formation of a vesicle is followed by its rupture which leaves a raw sur- 
face without a thickened inflammatory base and without loss of sub- 
stance. The burning or smarting is more acute and the inflammatory 
symptoms subside more quickly. The lymphatic glands of the groin 
may become inflamed, but do not suppurate. The duration of herpes 
is from eight to fifteen days. In chancroid the sore has an uneven, 
fissured base, the edges of which are sharply defined, and its surface 
is covered with a greenish discharge. It presents points of abrasion, 
shows an inclination to extend, and generally the apposed surface becomes 
inoculated. Bubo, or suppuration of the inguinal glands occurs. 

Treatment. In all forms of vulvitis absolute cleanliness is essential. 
In the simple acute variety, absolute rest and the administration of salines 
are indicated. Tincture of aconite can be given in drop doses every one 
or two hours to decrease inflammation. In all varieties thorough local 
cleanliness must be observed. In the simple and follicular forms 
cleansing and isolation of the inflamed parts frequently will be sufficient 
to establish a cure. The cause of the inflammation, if possible, should 
be determined, and, when practicable, remedial measures should be di- 
rected to its removal. Vaginal discharge should be arrested, and the 
inflamed surfaces should be protected from its contact. The rheumatic, 
gouty, and scrofulous diatheses and improper habits must be corrected 
by proper hygienic and constitutional measures. The food should be 
carefully regulated and all stimulating and indigestible articles avoided. 
Alcohol in any form should be interdicted, excepting in the diphtheric 
and phlegmonous varieties. In the acute stages a bland diet or exclusive 
milk diet may be advisable. 

The treatment of catarrhal and gonorrheal vulvitis is of great impor- 
tance, as in the latter infection may lurk in the diseased tissues for years. 
Cleanliness is secured by the employment of the hot sitz-bath several 
times daily, by antiseptic fomentations, such as gauze pads moistened 
with sublimate solution, 1:2000 or 1:1000; carbolic acid, 1:20; boric 
solution, 1 : 50; equal parts of boric-acid solution, and of a solution of sub- 
acetate of lead, or 5 per cent, solution of antipyrin, placed over the vulva and 
covered with oiled silk or rubber dam. In very acute conditions the distress 
will be more quickly ameliorated by the application of lead-water and 
laudanum which may be kept cold by an ice-bag placed over it. These 
applications, whether antiseptic or emollient, should be changed frequently, 
the parts protected from vaginal discharge by a tampon, and the inflamed 
surfaces painted several times daily with a solution of Monsell's salt, 
1 :8, in glycerin or 20 to 40 per cent, solution of argyrol; on each alternate 
day silver nitrate, gr. x to the fluidounce, or compound tincture of iodin 



INFLAMMATIONS. 307 

in water, i to 2, should be used. Protargol, largin, argyrol, and argonin 
have been especially advocated as valuable in the gonorrheal form; 
alumnol in 2 per cent, solution has also been advocated. Ramon 
Guiteras highly recommends mercurol in 2 per cent, solution. These 
agents are more effective in the gonorrheal form. The sides of the vulva 
should be separated with absorbent cotton, surgeon's lint, or prepared 
cotton. After the subsidence of the more acute stage the surfaces should 
be dusted with zinc oxid, bismuth subnitrate, iodoform, boric acid and 
acetanilid in equal parts, lycopodium, starch, talcum, or one of the various 
combinations of these powders. Iodoform and tannin in equal parts 
are very efficient. Equal parts of alum and sugar afford relief in pruritus. 
Buboes and abscesses should be promptly incised and their cavities steril- 
ized. In the former it is wise to dissect out the infected glands. In chronic 
vulvitis, astringents or caustics may be employed, the latter with the pur- 
pose of promoting sufficient metabolism to take up inflammatory exu- 
date which has led to thickening of the tissues. Benzoated zinc oint- 
ment is a soothing application. The surfaces may be dusted with cal- 
omel or bismuth subgallate. Gonorrheal vulvitis is usually secondary. 
In chancroid the parts should be kept clean by frequent washing, the 
inflamed area isolated by gauze or lint, and drying powders should be 
employed, such as iodoform, iodoform and tannic acid in equal parts, 
aristol and desiccated alum, 4 to i, calomel and zinc oxid, or bismuth 
subgallate and acetanilid. In herpes keep the surfaces clean and sepa- 
rated. Drying powders should be employed. 

In follicular vulvitis, in addition to strong antiseptics, alkaline solu- 
tions are efficient. It may be necessary to shave the parts and to punc- 
ture and cauterize the individual follicles, or, in rare cases, to excise the 
affected surface. The ointment of ammoniated mercury, diachylon 
ointment, or 5:25 per cent, ichthyol in lanolin (1:8-1:4) may be useful. 
Phlegmonous and diphtheric vulvitis require cleanliness, antiseptics, re- 
moval of sloughing tissue, and, in the latter, cauterization of the infected 
surfaces with strong carbolic acid. 

Eczema, when acute, must be treated with emollient applications, 
slippery-elm or starch poultices, and the surfaces should be carefully 
cleansed. The bowels should be regulated and constitutional measures 
employed for the correction of any disordered condition. When eczema 
is associated with diabetes, compresses of hyposulphite of soda, half 
an ounce to the pint, should be kept in contact with the inflamed surfaces. 
In chronic eczema the parts should be thoroughly washed with strong 
potash soap and hot water. By this measure all crusts and scales are 
removed. Where the surfaces are too much irritated, cracked, and fis- 
sured for this plan of treatment, a starch or slippery-elm poultice may pre- 
cede it. After thoroughly cleansing the surfaces, the application of the 
following ointments will prove of value: 

I^. Hydrarg. ammoniat., 3ss 

Lanolin, 5ij. M. 

Ft.ungt. 



3o8 GYNECOLOGY. 

I^. Iodoform., 5 j 

Zinc, oxid., 5ij 

Lanolin, oiij. M. 

Ft. ungt. 

^. Acetanilid, 5 j 

Menthol, 5ss 

Lanolin, 5 j. M. 

Ft. ungt. 

Diachylon ointment or one of the tar preparations may be substituted. 
Irritation apparently due to vaginal discharge may be overcome by the 
use of a medicated tampon. The bowels should be regulated and con- 
stitutional measures employed for the correction of arthritic, scrofulous, 
or diabetic conditions, any one of which may be the cause of this distressing 
disorder. 

233. Edema and Gangrene. Edema of the vulva is frequently 
associated with pregnancy. It is common in ascites from various ob- 
structions of the circulation. It may follow labor or result from varix 
of the external pudic vein. When one side of the vulva only is involved, 
infection should be suspected. Incisions of the vulva or spontaneous 
fissures permit the fluid to escape but increase the danger of erysipelas. 
They may be followed by gangrene and sloughing of the labia. The 
swelling in general anasarca is great, and may render urination or the 
use of the catheter difficult. 

A hard edema of one labium can occur from, and persist after, chancre. 
When it appears in the nymphse or praeputii clitoridis, it resembles ele- 
phantiasis. The condition is known as syphilitic hypertrophy of the 
vulva. 

Gangrene of the vulva may be caused by traumatism, or septicemia, 
and occur in weak and scrofulous infants. This form of gangrene in 
young children is known as noma. It is infectious, and presents a red- 
dened infiltrated labium and an ichorous discharge. A vesicle appears, 
which rapidly becomes gangrenous. 

The treatment of edema is the same as that of the condition from 
which it arises. That of gangrene or noma consists in early excision, 
disinfection, and the exercise of measures to secure effectual nourishment. 

234. Bartholinitis. Inflammation of the glands of Bartholin (known 
as the vulvovaginal, Duverney, or Cowper's glands) occurs in the race- 
mose glands the size of a bean, situated in the labia majora at the junction 
of the posterior and middle thirds. The duct, two centimeters in length, 
opens in front of the hymen, with an orifice the size of a pinhead. Catarrh 
of these glands is rare, but hypersecretion is not infrequent. It is indi- 
cated by redness about the opening of the duct, which may be either 
dilated or closed, in the latter case forming a retention cyst. The secre- 
tion from these glands may be thrown off in paroxysms, not infrequently 
in nocturnal emission. The secretion is particularly discharged during 
erotic excitement. 

Inflammation Can occur in either the gland or the duct. It is generally 
due to specific infection, but may arise from streptococcic or staphylococcic 



INFLAMMATIONS. 



309 



forms. In severe cases it is apt to be a mixed infection. It is most gener- 
ally due, however, to gonorrhea. Gonorrheal inflammation having been 
lighted up in the gland, it may subsequently remain dormant, and afford 
material which may not only infect the patient again, but others coming 
in contact with the secretion. Inflammation, according to its virulence, 
may either produce a cyst or result in the development of an abscess. 

Cysts are either single or multilocular, ovoid, with a smooth surface, 
and seldom transparent; the contents are viscid and are colorless or 
yellow. From mixture with blood they may become chocolate colored. 
(Fig. 308.) The cyst varies in size from 
that of a nut to that of an egg, is generally 
unilateral, and is most frequently situated 
on the left side, elongated in the axis of 
the greater lip, and neater the mucous 
surface. It seems elastic and compressible 
rather than fluctuating; gives rise to dis- 
comfort in walking and during coition, 
and can become inflamed and suppurate. 
Superficial cysts involving the duct may 
attain to the size of a nut; they are usually 
situated at the base of the labium minus, 
and may project into the vagina beneath 
the mucous membrane. A cyst of the 
gland is generally larger, deeper, and 
located behind the labium majus ; it elevates 
both labia, and its duct is impermeable. 

The diagnosis is readily determined. 
In either solid or fluid tumors fluctuation 
is absent, and the transparency is insuffi- 
cient. But when the diagnosis is doubtful, 
it can be ascertained by puncture. Condi- 
tions with which it may be confounded are : 
first, sacculated cysts of old hernial sacs; 

second, hydroceles in the canal of Nuck; third, a cyst in front of a hernia. 
From hernia, which may be an epiplocele, an enterocele, or ovarian, it is 
distinguished by the absence of succussion in coughing and by the determi- 
nation of the connection of the mass with the abdomen. Hydrocele 
frequently may be displaced by pressure, is a larger tumor, gives more 
sensation of fluctuation, and is more translucent. Abscess may be 
secondary to the cyst or may originate from primary inflammation. Swell- 
ing and edema are marked over the posterior part of the vulva and about 
the anus, and the pain is acute and lancinating. The patient may have 
more or less fever; frequendy, the urine is retained ; fluctuation is distinct, 
and, if the abscess is not opened early, its contents may escape through 
several openings; pus is abundant and fetid. Fistulas may persist, and 
may result in a rectovulvar fistula, or a large ulcer may be present, asso- 
ciated with purulent secretion or a hypertrophic induration of the gland, 
with profuse discharge of mflky, greenish pus. The gland is prone to in- 




FiG. 308.— Cyst of Bartholin's Gland. 



3IO GYNECOLOGY. 

vasion by gonorrheal inflammation and is a frequent source for unsuspected 
infection in men. It may be confused with anal abscess, phlegmon of 
the labium majus, or furuncles. In anal abscess there is more rectal 
disturbance, a more widely diffused inflammation, and the mass does not 
encroach to the same degree upon the labium. In phlegmon of the la- 
bium majus the inflammation is more external, and encroaches upon the 
cutaneous rather than upon the mucous surface. Furuncles are more 
sharply defined and present an indurated base. 

Treatment. In early inflammation of the duct the pus may be evacu- 
ated by pressure and the gland injected with a two per cent, sterile solution 
of ichthyol, or a one per cent, solution of silver nitrate. The duct may 
be opened with a lacrimal knife, and a crayon of silver nitrate or a solu- 
tion of zinc chlorid (i : 50) may be introduced. In cysts, when the con- 
tents are evacuated by puncture, they quickly reappear. Obliteration of 
the cyst may be secured by injecting ten drops of a solution of zinc chlorid 
(1:10) after the contents have been removed by aspiration, or the cyst 
may be incised and packed with iodoform gauze. A preferable procedure 
would be extirpation. In order to overcome the difficulty of removing 
the cyst when collapsed, it may be punctured, emptied, irrigated with 
hot water, and injected with melted paraffin, and the latter hardened 
with ice, after which the mass thus formed is easily dissected. The wound 
produced by the removal of a cyst should be closed with sutures. In 
abscess early free incision at the junction of the skin and mucous surface 
is important. To extirpate the gland, wash the cavity with carbolic solu- 
tion and pack with gauze. In fistulae it may be wise to extirpate the 
gland, dissect out the fistulous track, and close the cavity with catgut 
sutures. 

235. Pruritus vulvae is a symptom of all forms of inflammation of the 
vulva. It results from the presence of pediculi, pin-worms, eczema, 
trichiasis; from hemorrhoids, disease of the kidneys, ureters, bladder, and 
urethra; from congestion of the pelvic organs and masturbation; and from 
acrid vaginal discharges. It is associated with pregnancy, menstruation, 
the menopause, old age, the gouty diathesis, and general nervousness. 
It is directly caused by lice, acrid discharges, and diabetes. In addition 
to the sources given, there is a form of pruritus in which the origin remains 
undetermined. This is designated as an idiopathic pruritus. It is, how- 
ever, very questionable whether careful examination will not disclose a 
demonstrable cause of the disorder. Seeligman, in an investigation of a 
large number of cases, found in all a diplococcus which resembles the 
gonococcus in appearance, but differs from it in its process of growth, and, 
besides, it takes the Gram stain. 

Symptoms. Pruritus produces intense itching, and, as a result of the 
scratching induced, excoriations are present. The hair is often worn 
off the mons veneris. The patient avoids company, becomes melancholy, 
has loss of appetite and sleep and increased sexual desire, masturbation is 
excited, and she may become insane. Itching is continuous or occurs 
only at intervals; it is increased by heat and is much worse at night or 
following any exertion. The relation of masturbation to pruritus is not 



INFLAMMATIONS. 3II 

determined readily. The habit produces certain abnormal alterations as 
a result of the irritation: changes in the endometrium, glandular hyper- 
trophy, ovarian irritation, increase of secretion, irritation and manipula- 
tion of the vulva. A bad circle is engendered; irritation causes masturba- 
tion, and this aggravates the inflammation. There are cases, however, 
in which most careful examination fails to disclose inflammation of the 
vulva as a source of the intense pruritus. These conditions are known as 
idiopathic pruritus, and are supposed to be due to nerve irritation. Such 
cases do not properly belong under the term inflammation of the vulva, 
but they are so rare, and the symptoms are so prominently associated with 
vulvitis, that their consideration seems more appropriate here. 

Prognosis. The relief of the condition depends entirely upon its cause. 
In some cases it is exceedingly obstinate. The removal of the cause, as 
fllth, pediculi, or pin-worms, results in the removal of the disorder. The 
prognosis in masturbating alterations is by no means favorable. It may 
be exceedingly difficult to overcome the evil habit. 

Treatment. The first aim in the treatment should be to discover and 
remove the cause. Upon the recognition of pediculi the parts should be 
shaved, and blue ointment should be applied. A strong sublimate solution, 
however, is the most effective agent. The surfaces should be painted 
with a solution containing one grain of corrosive sublimate to the ounce 
each of alcohol and water. Unless the parts are shaved, this application 
must be made repeatedly, for it is necessary to destroy not only the lice 
which are present, but also the spores. If the pruritus arise from the 
action of the ascarides scabiei (the itch insect), sulphur ointment or one 
consisting of thirty-five grains of betanaphthol in one ounce of vaselin is 
an efficient application. Of course, in the latter condition, the application 
must be made to the entire body. 

The methods of treatment of eczema and vulvitis have already been 
given. When it is evident that the pruritus has been produced by pin- 
worms, the parts should be kept clean and the patient given fluidextract 
of senna and spigelia in half-ounce doses; a rectal injection of infusion 
of quassia, two ounces to the pint; half a grain of sublimate to eight 
ounces of water; an injection of lime-water, or a suppository of five grains 
of santonin, are all efficient measures. Hemorrhoids, glycosuria, and 
other causes should be recognized and treated. The diet is important. 
Alcohol and spiced food should be excluded. The use of coffee will 
often cause severe pruritus. Milk is an excellent basis for the diet. The 
general health should be carefully considered. Tonics, such as arsenic 
and quinin, should be administered. When the patient is unable to rest, 
sleep should be secured by the administration of bromid of potash, 5j~ 
5ij daily, tincture of cannabis indica, gtt. xx-xxv, thrice daily, or a cap- 
sule containing camphor gr. ss chloretone gr. x at night. If necessary 
this may be repeated every hour for three doses. When the measures 
just named are insufficient to secure sleep, sulphonal, trional, or veronal 
should be given in preference to opium. Local vaginal injections of 
hot water; carbolized, sublimated, or borated cotton tampons; or fomen- 
tations of lead-water and laudanum can be employed, or a saturated 



312 GYNECOLOGY. 

solution of bromid of potash may be painted over the surface several 
times daily. Local applications of chloroform in glycerin (i:8), hydro- 
cyanic acid, two or three drops to the ounce, or a one per cent, solution of 
cocain may be used. A solution of carbolic acid, or a strong solution of 
silver nitrate, followed by cold compresses, may be employed. Seelig- 
man advocates the use of an ointment containing lo per cent, of guaiacol 
in vaselin, and when this is not effective, it should be increased to 15 to 
20 per cent. An ointment containing acetate of lead, chloral, camphor, 
or chloroform (a dram to the ounce), combined with vaselin, menthol, 
or a solid stick of nitrate of silver, is advised. The following formula 
may be employed: 

I^. Menthol, 3ss 

Lanolin, 5 j. M. 

Ft. ungt. 

In very obstinate cases the affected skin may be excised. Tampons 
containing equal parts of sulphurous' acid and boroglycerid sometimes 
afford relief. The irritated surfaces may be painted with a solid stick of 
silver nitrate or a galvanic current can be employed. The employment 
, of the x-rays has been advocated. The resort to tobacco smoking has 
afforded relief when all other means have failed. 

236. Kraurosis vulvae is an obscure form of disease, first recog- 
nized by Breisky. It consists of an atrophy of the smaller lab'.a. (Fig. 
309.) The skin of the vulva undergoes essential changes. The capil- 
laries of the corium become dilated, the rete mucosum gets thin and dis- 
appears, while there is a substitution of a thick horny layer of epithelium, 
which lies directly upon the corium. The papillae disappear, the undu- 
lating character of the skin is lost, and it becomes stiff and sclerosed, 
with here and there points of small cell infiltration. As the disease 
progresses the sebaceous and sweat-glands are entirely destroyed. It is 
called chronic inflammatory hyperplasia of the connective tissue with 
inclination to cicatricial shrinking (Peter). 

Mars divides kraurosis into two stages: (i) The stage of edema, 
'Characterized by more or less inflammatory reaction; (2) the atrophy of 
elastic and connective-tissue skin layers with the formation of scar tissue; 
but Heller says it may be independent of the inflammatory process. He 
attributes it to some chemic irritation or a direct disease of the medullated 
nerves, which leads to atrophy of the muscles, fat, and glands in the deeper 
layers of the skin, while a hypertrophic process, especially a hyperker- 
.atosis, occurs in the superficial layer. 

Causes. The cause is unknown. It has been attributed to gonorrhea 
and pruritus. A preceding inflammatory stage exists (Martin). Breisky 
found it more frequently in the pregnant; Martin and others, in the non- 
pregnant. 

Symptoms. The surfaces become contracted, presenting a smooth, 
cicatricial appearance, devoid of glands, with reddened, inflamed points, 
not fully cicatrized. Pruritus is intense and causes severe burning and 
pain upon urination. The surface is dry, smooth, contracted, often 



INFLAMMATIONS, 



3^3 



fissured. The labia minora entirely disappear, and the clitoris becomes 
a mere papule. The vulvar orifice is contracted, and causes coition to be 
exceedingly painful, often impossible. Childbirth results in extensive 
laceration. 

Diagnosis. The lesions induced by scratching in this disease should 
be distinguished from that of onanism and pruritus. The gratification 
induced by masturbation and the absence of cicatricial changes distin- 
guish it. In pruritus the tears and superficial injuries are more 




Fig 309. — Kraurosis Vulvae. 



marked and the disease is not so general, while in kraurosis the border 
of disease is more sharply defined toward the healthy skin. 

Prognosis. Its spontaneous recovery is very doubtful. That carci- 
noma occasionally develops from it is exceedingly probable. 

Treatment. The disease is exceedingly intractable to treatment. The 
application of cocain adds to the discomfort. Relief has been afforded 
by applications of strong carbolic acid, or of pledgets wet with a solution 
of lead acetate. The thermocautery has been applied. The most effect- 
ive treatment is the excision of the affected tissue, accomplishing union 



314 GYNECOLOGY. 

of the healthy tissue by sutures. Care must be exercised to prevent 
narrowing of the urethra. 

237. Urethritis is an exceedingly painful, but not an unusual, 
complication of pelvic abdominal procedures where a catheter has been 
employed. 

Varieties. It may be manifest as a simple hyperemia, an acute 
catarrhal urethritis, a chronic interstitial urethritis, or a granular or 
follicular urethritis. Associated with the urethral inflammation ulcera- 
tion, fissures and a sacculated condition of the urethra occasionally 
occur. 

Hyperemia may result from injury during a difficult labor; from uterine 
displacement and uterine growths affecting the pelvic circulation; from 
varicose veins, irregular urination, excessive coitus, or long-continued 
irritation. Probably the most frequent cause of hyperemia, which may 
continue until inflammation results, is the repeated use of the catheter. 
So probable is such a result that the majority of operators prefer, if 
possible, to have the patient evacuate the urine unaided. When the use 
of the catheter is necessary, the operator should have the nurse introduce 
the instrument for the first time in his presence, so that he can observe 
what precautions she employs and determine the ease with which she 
can accomplish the procedure. The instrument should never be intro- 
duced by touch, but always by sight. The vulva and the vestibule are 
generally covered with discharge, which is filled with micro-organisms 
capable of producing serious discomfort when carried into the urethra 
and bladder. 

The labia minora should be separated and the vestibule sponged 
with absorbent cotton saturated with an antiseptic solution. The 
instrument, preferably of glass, should be perfectly smooth, with no 
rough or cutting edges. It should be boiled, kept in an antiseptic solu- 
tion, and previous to its use washed with sterile water. It is then anointed 
with carbolized vaselin and carried by gentle pressure upward and back- 
ward, without exercising any force. If the passage of the catheter is 
obstructed, withdraw and reintroduce it, as the instrument may have 
entered one of Skene's follicles. 

Even with the exercise of every precaution the urethra so often is 
irritated by the frequent introduction of the catheter that the patient may 
suffer more distress than from the condition for which the operation was 
performed. Consequently, whenever the patient can evacuate the bladder 
unaided, she should be encouraged to continue to do so, as the contact 
of healthy urine with a plastic wound, if the precaution is observed to 
irrigate the latter immediately, is less harmful than frequent catheteriza- 
tion would be. 

In operations upon the bladder which require the urine to be evacu- 
ated frequently, a self-retaining catheter should be left in place several 
days. (Fig. 235.) A soft-rubber instrument with a flange upon its 
vesical end is most serviceable. It can be plugged, permitting the urine 
to collect for two or three hours. It should not be permitted to remain 
longer than forty-eight hours without removal and careful cleansing. 



INFLAMMATIONS. 315 

The ordinary glass catheter, with a long rubber tube attached, in my ex- 
perience, does equally well. 

In acute catarrhal urethritis the mucous membrane becomes thickened ; 
its papillae are hypertrophied and are covered with an imperfectly 
developed epithelium. At points the latter is desquamated and the 
papillae are enlarged. This may result in the formation of a polypoid 
mass, which projects from the surface frequently by a pedicle — the ure- 
thral caruncle. 

The acute disease may arise from long-continued and repeated hyper- 
mia or from traumatism, but it most frequently results from gonorrheal 
infection. The urethra is often the first point affected. 

Symptoms. The onset of the acute attack is at first made known by 
itching or smarting of the urethral orifice, as the contact of the urine gives 
a sensation of a hot scalding liquid and urination is followed by intense 
burning along the course of the urethra. The meatus becomes red and 
swollen, then dark red and pouting. It is tender to the touch, and pres- 
sure along the urethra causes a few drops of mucopurulent or purulent 
secretion to be discharged. If the disease does not extend to the bladder, 
the symptoms soon subside or disappear. 

Diagnosis. The condition should not be confounded with cystitis. 
Urination is not frequent. The pain and distress are associated with 
micturition, especially in getting the urine started, while in the intervals 
there is comparative relief. The tenesmus of urethritis can be controlled; 
it is attended with scalding, but is relieved by urination. In cystitis the 
tenesmus is uncontrollable, unrelieved by urination, and there is no 
urethral burning. 

Chronic catarrhal urethritis is very generally an interstitial inflamma- 
tion. The membrane is thickened and the canal narrowed, not infre- 
quently permanently so, which results in a stricture. 

Symptoms. Urination is frequent. Temporary retention of urine 
may, however, be caused by a spasmodic stricture. The latter is greatly 
aggravated by frequent coition or prolonged exercise. The thickening 
of the urethra is apparent upon passing the finger down its course along 
the anterior wall of the vagina. A small sound can be passed through the 
urethra, while the introduction of a large one meets with resistance and 
produces severe pain. 

Follicular inflammation involves the follicles about the orifice of the 
urethra and Skene's glands. The latter are two tubules which will 
admit a No. i probe (French scale), and are situated in the floor of the 
female urethra, extending upward from the meatus about one or two 
centimeters. In the normal condition the orifices of the tubules are 
three millimeters within the meatus, but with the urethra slightly pro- 
lapsed and the meatus everted, the orifices may be exposed to view. The 
upper ends of these canals terminate in a number of divisions, which 
project into the muscular wall of the urethra. (Fig. 310.) These tu- 
bules occasionally become so much enlarged as to permit the introduction 
of a small catheter. If such an instrument were forcibly introduced, it 
would tear through the tubule and establish a false passage. Such a 



3i6 



GYNECOLOGY. 



passage might enter the urethra or pass beneath it into the tissue and 
thus enter the bladder. In one patient under my observation the ex- 
ternal orifice closed, these ducts formed cysts so large as to project be- 
beyond the meatus, and nearly a drachm of mucopurulent fluid was 
discharged from the two. Follicles and tubules about the urethral orifice 
may become inflamed, with the consequent discharge of mucus and pus. 
The mucous membrane may become thickened or the orifices closed. 
The latter will result in the formation of small cysts. 

The symptoms are great tenderness; discomfort in sitting, standing, or 
walking; dyspareunia; stinging pain; a sensation of heat; and frequent 
and painful micturition. The orifice of the 
meatus is partly everted, with red, puffy folds, 
which simulate caruncle. There is erosion of the 
labia minora and of the edge of the meatus. A 
few drops of purulent discharge can be extruded 
by pressure along the urethra. 

Ulceration is produced as a result of trauma- 
tism, from calculi, unskilful use of the catheter, 
specific infection, or the presence of diphtheric or 
venereal poison. 

During the passage of a calculus or while in 
labor, injury, laceration, or overdistention of the 
middle portion of the canal occurs, with contrac- 
tion of the meatus. A small quantity of urine and 
mucus is retained, which decomposes, and results 
in the development of inflammation and in the 
production of a condition simulating an abscess. 

Symptoms. The most prominent symptom is 
dysuria, which becomes chronic. The meatus is 
large, of a deep-red color, granular appearance, 
and sensitive to pressure. The passage of an ordinary sound is readily 
accomplished, but is attended with pain. Sometimes a drop of blood 
is discharged. The sacculated form is associated with a copious dis- 
charge of pus, particularly when pressure is made along the urethra. 
Even when the discharge of urine is perfectly clear, pressure will cause a 
considerable discharge of pus. 

Vesico-urethral fissure holds an intermediary position between cystitis 
and urethritis, and strikingly resembles both. Its cause is undetermined. 
The fissure is situated at the internal meatus, and resembles a crack in 
the lip or an ulcer similar to that which is found in fissure of the anus. 
The fissure is usually considered as being situated in the neck, but, as 
a rule, two-thirds of it is in the urethra. Only the upper end of it ex- 
tends into the bladder. It may occur at any part of the circumference 
of the urethra, but, according to Skene, it is in the majority of cases 
situated upon the right side. In length it is from six millimeters to one 
centimeter, and is*from two millimeters to four millimeters in width at 
the widest part. It is deeper at either end. The deepest portion, yellow- 
ish gray in color, resembles an indolent ulcer, while its edges are red and 




Fig. 310. — Urethra Laid 
Open with Probes, Dis- 
tending Skene's Glands. 
Posterior Wall Divided. 
(By ford, after Skene.) 



INFLAMMATIONS. 317 

inflamed. Through an endoscope it looks like a fresh tear, the edges of 
which are abrupt, elevated, and indurated. Its situation explains the 
attendant discomfort. In any other portion of the urethra it produces 
little inconvenience beyond a smarting sensation, but at the junction of 
the bladder and urethra it is subject to constant though slight pressure, 
which causes severe and continuous pain. The portion of the fissure 
extending into the bladder is exposed to irritation from contact with the 
urine, producing a constant desire to urinate, a sensation of burning at 
the neck of the badder, acute pain during and immediately following 
micturition, and severe tenesmus, causing the patient to continue straining 
efforts after emptying the bladder. The pain and burning immediately 
following micturition are often intense. Subsequently, it partly sub- 
sides, to return with the accumulation of a small quantity of urine. If 
the patient resists the inclination to urinate, the distress is greatly 
aggravated. 

Diagnosis of Urethral Inflammations. The recognition of inflamma- 
tion of the urethra is often difficult, because it is frequently complicated 
by inflammation of the bladder. Acute catarrhal inflammation of non- 
specific origin usually begins gradually, and is often preceded by uterine 
or vesical symptoms, while the gonorrheal variety appears abruptly, 
and is preceded or attended by acute vaginitis or vulvitis. 

In both varieties urination is painful. Sharp scalding is produced 
by urine passing over the inflamed surface, but the desire to urinate is not 
so frequent or urgent as in cystitis. Often the urine is long retained, for 
fear of the pain occasioned by its evacuation, or started with difficulty, 
because of the sensation of scalding as the urine comes in contact with 
the inflamed surface. 

Slight hemorrhage is occasionally noticed, the urethral origin of which 
is evident as the blood is unmixed with urine, a few drops oozing from the 
external meatus subsequent to urination. Urethral discharge is common, 
and, except just after urination, it can be extruded from the orifice by 
pressing upon the urethra from the vagina. Microscopic examination 
of the discharge may reveal the presence of gonococci, which makes the 
nature of the urethritis absolutely certain. However, the absence of 
this germ cannot be accepted as positive proof that it is not of gonor- 
rheal origin. To exclude cystitis, introduce the catheter, allow some 
urine to escape to wash away the mucus introduced with the instrument, 
and retain the remainder, which will be found free from sediment. Pres- 
sure along the urethra from the vagina is painful in urethritis, while 
pressure over the bladder, unless complicated by cystitis, is not dis- 
tressing. 

In chronic urethritis the urethra is less sensitive, but it will be noticed 
as a somewhat thickened cord when examined from the vagina. 

In granular erosion the pain during micturition is excruciating, it is 
associated and followed by tenesmus, and is more likely to be found in 
old persons. 

The character of the disease is assured by its history and by the ap- 
pearance of the urethra. Fissure, urethritis, and cystitis are distinguished, 



3l8 GYNECOLOGY. 

the latter especially, by examination of the urine. Fissure alone is 
free from all the products of cystitis. Urethritis is excluded and the fis- 
sure detected by the use of the endoscope. The endoscope is more 
satisfactory than the ordinary open instrument, because it exposes the 
surface of the fissure, which would be overlooked with the open end 
instrument. As a rule, the pain in fissure is more circumscribed than in 
either urethritis or cystitis, and in many cases more acute. 

The maximum of pain in fissure follows urination, while in cystitis 
there is a sense of relief. In urethritis the most severe pain occurs dur- 
ing the act of urination. It then subsides slowly. 

Treatment of Urethral Inflammations. In urethral hyperemia render 
the urine bland and unirritating by the exclusion of acids and stimulants 
from the diet and by the administration of saline cathartics. Relief is 
enhanced by giving ten grains of benzoate of ammonia or benzoate of 
sodium every three or four hours, and by the employment of hot hip- 
baths and hot vaginal douches. 

Acute urethritis, whether specific or otherwise, should be treated upon 
the same principles as in gonorrhea of the male. The treatment consists 
of constitutional and local measures. Internally, salicylic acid in ten- 
grain doses lessens the discharge. Salol, two grains every two hours 
with a glass of hot water, renders the urine bland and unirritating. 
Douche the urethra frequently with hot water through a reflux catheter 
(Fig. 311), so that the current flows back from a cap on the end of the 
instrument. Later, inject from one-half of one to one per cent, of car- 
bolized water; sublimate, gr. 1/40, to aq., fgj; silver nitrate, gr. 1/6, 
to aq., fgj; or zinc chlorid, gr. x, to aq. fgj; preceded, when injection is 
painful, by the instillation of a solution of cocain with a pipet. 

In making urethral applications it should not be forgotten that the 
canal will hold but from ten to fifteen drops. If a larger quantity is 
thrown in by the pipet, it flows into the bladder. A strong solution of 
silver nitrate (gr. x-xv to aq. f 5 j) may be applied by a pipet or applica- 
tor. The same quantity of a twenty per cent, solution of argyrol may be 
employed frequently with very little discomfort and with very beneficial 
results. 

Internally may be administered those remedies which will have an 
inhibitory influence through the urine. These so-called blennorrhagic 
remedies are: copaiba, cubebs, sandalwood oil, urotropin, aminoform, 
helmitol, and thyresol. 

The itching of subacute and chronic urethritis may be alleviated by 
applications of different combinations of chloral or hydrocyanic acid, 
as in the following prescriptions: 

I^. Chloral, 9 iv 

Lanolin, 5 j. M. 

Ft. ungt. 

I^. Chloral, 

Camphor, aa gr. xxx 

Lanolin, S j. M. 

Ft. ungt. 



INFLAMMATIONS. 319 

I^. Acid, hydrocyan. dil., o j 

Plumbi acet., gr. xv 

Glycerin, f 5 j. M. 

These remedies may be brought in contact with the affected surface 
by the applicator. A suppository or bacillum of cocain in cacao-butter, 
or in combination with lead acetate, will give relief. These bacilla 
should be introduced into the urethra two or three times in the twenty- 
four hours, preferably after urinating. In prolonged chronic disease 
which has resulted in thickened walls and a more or less contracted 
canal, the dilatation of the urethra by bougies once or twice weekly will 
be beneficial. 

The bougie may be anointed for introduction with mercuric oleate, 
the ofl&cial ointment of mercury, or any other medicinal agent which will 
have a beneficial influence upon the mucous surface. M. Julien, of 
Paris, applies ichthyol by dipping into it a cotton-wrapped probe, which 
is passed and repassed into the urethra several times. This agent has a 
destructive influence upon the gonococcus. 

Granular erosion is best treated by brushing pure carbolic acid or 
silver nitrate (gr. xv to aq. f g j) over the surface. This should be repeated 
in eight or ten days. The urethra should be dilated previously. Fol- 
lowing the subsidence of the acute symptoms, a few drops of a solution 
of zinc sulphate, gr. iv, fluidextract of hydrastis canadensis, fgj, aq., 
fgiij, may be used twice weekly with a pipet. Mercurol, 2 per cent, 
solution, has been found very serviceable. 

In fissure, instillations and injections do harm by increasing the 
spasmodic contraction of the bladder, and they add greatly to the dis- 
comfort of the patient. 

A fissure may be exposed by a fenestrated speculum, and dusted with 
calomel, finely pulverized iodoform, or bismuth subnitrate, or the miti- 
gated stick of silver nitrate may be employed. Incision of the fissure, 
as performed in anal fissure, is successful. The urethra should have 
been dilated previously. Dilatation is one of the most effective methods 
of treating fissure. The precaution must be exercised, however, not to 
overdilate the urethra and thus produce permanent incontinence. 

Follicular urethritis is most effectively treated by splitting up the tubes 
their entire length. This may be done with the thermocautery, or they 
may be cauterized with carbolic acid and subsequently treated with 
milder agents, as in urethritis. In such cases, however, splitting up the 
canal is a prerequisite to cure. 

238 e Cystitis is an inflammation of the mucous membrane of the 
bladder, and may be either acute or chronic. 

Etiology. The bladder is in intimate muscular relation with the 
uterus, as well as dependent upon the same nerve centers and ganglia 
for its nervous distribution. A portion of the bladder lies in direct con- 
tact with the cervix, but in closer relation with the vagina. It is not 
surprising, then, with such intimate relations, that the condition of the 
bladder should be affected by disorders of the uterus. 

Inflammatory conditions of the bladder, if they have not originated 



320 GYNECOLOGY. 

from disorders of the uterus, are aggravated thereby. The symptoms of 
cystitis are more marked during menstruation and greatly aggravated 
by metritis. Vesical symptoms are engendered by uterine and vaginal 
displacements, by subinvolution and hypertrophy, by tumors and preg- 
nancy, by pelvic cellulitis, and pelvic peritonitis. The train of phenomena 
thus engendered may be enumerated as: difficulty in evacuation; reten- 
tion and decomposition of the urine, producing irritation, and finally 
cystitis. Cystitis may be secondary to inflammation of the kidneys, 
ureters, or urethra. Chemic modifications of the urine may result from 
indiscretions in diet, from the administration of irritating drugs, or from 
affections of the central nervous system. Inflammation is produced 
by traumatisms, injuries from the introduction of a catheter, or the pres- 
ence within the bladder of a rough calculus. 

Without doubt, the most frequent cause of cystitis is infection. This 
may result from the deposition of bacteria by the blood, from the exten- 




FiG. 311. — Reflux Catheter. 

sion of inflammation from neighboring organs, or the introduction of 
infection by way of the urethra. The infection is generally introduced 
into the bladder from the employment of the catheter. A violent form 
of cystitis is produced by retention of urine. A pregnant retroflexed 
uterus which has become impacted in the pelvis, by pressure upon the 
neck of the bladder, not infrequently leads to gangrene and desquama- 
tion, or to separation en masse of the entire vesical mucous membrane. 
Neoplasms, such as cancer, tuberculosis, polypi, and villous tumors, 
will usually excite a cystitis. 

Pathologic Changes. The mucous membrane becomes injected, 
particularly about the orifices of the ureters and internal meatus. As 
the inflammation progresses the entire mucous membrane is swollen and 
becomes a bright red. The epithelium is desquamated and patches of 
ulceration or hypertrophied papillae appear, which bleed easily. Abscesses 
develop in the vesical wall. The micro-organism most frequently found 
is the bacillus coli communis. Disease is also induced by the staphylo- 
coccus, the gonococcus, and the bacillus tuberculosis. 

Symptoms of Acute Cystitis. Acute inflammation of the bladder is 
characterized by painful micturition; frequent desire to void urine, with 
only a few drops discharged at each attempt; severe vesical, and fre- 
quently rectal, tenesmus; a sensation of fullness or weight in the hypogas- 
trium; shooting pains in the perineum and anus; and a burning, lanci- 
nating pain, like a hot iron, in the urethra. These attacks may be almost 
continuous, or may, after a time, subside, to recur again in an hour or so. 
Examination by touch, whether over the abdomen or by the vagina or 



INFLAMMATIONS. 32 1 

rectum, is extremely painful. The urine is scanty, highly colored, and 
becomes cloudy after standing. In very severe attacks the urine becomes 
a dark red color and contains blood and pus-corpuscles and uric-acid 
crystals. 

Constitutional disturbances are marked. These are nervous excite- 
ment, insomnia, and anorexia, followed by emaciation and loss of strength. 
Uncomplicated vesical inflammation does not cause elevation of temper- 
ature (Guyon). Partial or complete retention of urine is frequent. 
Paroxysmal pain results from vesical distention, and there may be fre- 
quent evacuation or continuous dribbling of urine without at any time 
emptying the bladder — an evidence of overflow known as the incontinence 
of retention. The course and duration of the disease are variable: it 
may subside in a few days or may continue alternately better and worse 
for weeks. 

Symptoms of chronic cystitis are less pronounced, though similar 
to those of the acute disease. Micturition is frequent and painful, often 
difficult. The pain is pronounced at the beginning of the evacuation, 
thus leading to delay in starting. Exposure to cold, dampness, changes 
of clothing, indiscretions in diet, or constipation lead to acute or sub- 
acute attacks. The urine, after standing, becomes cloudy, and contains 
blood and pus-corpuscles, mucus, and uric-acid crystals. If drawn with 
the catheter, it is at first clear, then turbid, and toward the last pus ap- 
parently is discharged. The microscope reveals leukocytes, epithelial 
cells, tissue debris, and salt crystals. When the urine stands, it becomes 
alkaline, and bacteria in abundance are found. 

Constitutional Condition. The patient is easily fatigued, has no 
appetite, loses flesh, develops a cachexia, has repeated inflammatory 
attacks associated with fever, repeated chills, a more or less continuous 
diarrhea, profuse sweating, and, finally, a fatal termination results. 
Such a train of symptoms and such a termination indicate the presence 
of an infectious pyelonephritis as a complication. 

Cystitis of gonorrheal origin is produced by the extension of gonorrheal 
infection from the urethra, possibly through the careless employment 
of the catheter, but more frequently from the continuation of urethritis 
to the bladder. Its principal symptoms are frequent micturition, agon- 
izing pain in the acute stages, associated with changes in the quality of 
the urine; hematuria is a common symptom, but is rarely profuse. These 
symptoms do not occur in the early stage of the infection. The disease 
is then generally much milder, characterized only by tenesmus. In the 
mucopus of the urine, from the associated urethritis, the gonococcus may 
be found. 

Tubercular cystitis causes symptoms very similar to those produced 
by inflammation from gonorrhea and the irritation of calculi. Hema- 
turia is a symptom in all varieties, but differs in tuberculosis. It appears 
early in the disease, and the blood is generally mixed with the last drops 
of urine. The bleeding ceases as the disease advances. In common 
with other vesical inflammations, pain, urethral spasm, and retention 
and incontinence of urine are marked. 



322 GYNECOLOGY. 

Diagnosis of cystitis is not difi&cult. The frequent micturition, pain, 
alkaline reaction of the urine, large quantity of sediment, and mucopur- 
ulent appearance are ample evidence. In cystalgia and functional dis- 
eases of the bladder the urine will be found clear. Probably the greatest 
difhculty will be experienced in differentiating pyelonephrosis which 
may be the cause of the cystitis. The prognosis and method of treatment 
must depend upon the accurate determination of the structures involved. 

The existence of pyelonephrosis is recognized by finding the urine 
unaltered after irrigation of the bladder, while in cystitis it becomes clear. 
The condition of the urine from each kidney is recognized by securing the 
urine separately through catheterization of the ureters or by the employ- 
ment of the Harris segregator. 

The careful investigation of the urine will often be sufficient to de- 
termine the diagnosis. Albumin is contained in the urine in either cys- 
titis or pyelitis, but in very slight amount in the former, while it is present 
in quite large proportions in the latter. 

The presence of a proportionately great abundance of albumin in 
the urine, associated with pus, should be considered as indicating the 
presence of renal disease. The most frequent cause is tuberculosis. The 
diagnosis of tuberculosis of the urinary tract is determined by the presence 
of the tubercle bacillus in the urine. However, Dr. Joseph Walsh, of 
Philadelphia, associated with Dr. Flick in his investigations in tubercu- 
losis, informs me that the tubercle bacillus is found more frequently 
in the urine of the tubercular patients than is generally supposed. The 
great majority of these patients will be found not to have a tuberculosis 
kidney, though they will show a catarrhal condition of the kidneys, which 
is manifested by pains or aching in the bones, and by the presence in the 
urine of epithelial or granular casts, pus, and sometimes albumin. The 
bacilli may be found in the urine without any inflammatory symptoms. 
In sixty nonselected tuberculous patients whose urine Dr. Walsh exam- 
ined, the bacilli were recognized in forty-four; in thirty of these the disease 
was in an advanced stage; in ten it was considered marked, and in four, 
only incipient. In patients in the advanced stages of the disease it is 
rarely that the bacilli will not be found in the urine. In five of the 
forty-four cases above cited tubercle bacilli were found in the urine, but 
not in the sputum, though the presence of a pulmonary lesion was recog- 
nizable. I have quoted Dr. Walsh fully, because his investigations seem 
to demonstrate that the presence of tubercle bacilli in the urine cannot 
be accepted as evidence of the existence of a true renal lesion. The 
usually recognized difficulty of finding the bacilli in the urine is my justi- 
fication for quoting here Dr. Walsh's method of examination: 

" Six fluidounces of urine are centrifugated in a water motor centrifuge; 
the sediment is then poured on one or two cover-glasses and allowed to dry 
thoroughly (twenty-four to forty-eight hours) . The process is complicated 
by an excess of the crystalline sediment, which may render it impossible 
to find the micro-organism. In such cases, therefore, the sediment se- 
cured by centrifugation should be dissolved in water, a weak nitric acid, 
or a caustic potash solution, and again subjected to the centrifuge. In 



INFLAMMATIONS. 323 

rare cases the sediment may resist any one or all of these solutions. Af- 
ter drying, it is fixed to the cover-glass by passing the latter through a 
flame two or three times, repeating this procedure twice, at intervals of 
a minute or two. The procedure for determination of the bacillus in 
urine requires more heat than the corresponding examination of the spu- 
tum. Even after the procedure for fixing given, the sediment will oc- 
casionally be washed off by the running water and the specimen thus 
destroyed. 

"The specimen is stained with carbol-fuchsin for three to five minutes 
or longer, washed in turn with 95 per cent, and absolute alcohol for one 
to three minutes, decolorized, and counterstained with Gabbet's solution. 
The greater number of foreign elements in the urine, some of which hold 
the fuchsin, makes a larger experience necessary for the recognition of 
the bacilli than is requisite in sputum. 

"The organisms must be absolutely typical to render the diagnosis 
certain." 

In examining over the abdomen of a patient suffering from tubercu- 
lous cystitis, greater pain is experienced by suddenly withdrawing the 
hand pressure than is produced by deep palpation. A cystoscopic ex- 
ploration of the bladder will reveal the extent of involvement and 
amount of tissue destruction. Tuberculous cystitis may supervene upon 
the gonorrheal, without cessation of the latter. The bladder wall is 
thickened with masses or projections from the surface. These may break 
down in extensive ulceration, or may be manifest in a single ulcer. 

Primary vesical tuberculosis is manifested by a very irritable bladder, 
frequent and painful micturition, followed by the passage of a few drops 
of blood. Such symptoms may subside, to be followed by an aggravated 
attack. The presence of pus in the urine indicates preexisting disease, 
which may have been unsuspected. The progress of the disease is more 
rapid when complicated by the discharge of pus, the presence of a fistula, 
or the existence of pyelonephritis. The last complication should be 
suspected when the urine shows the presence of a large pus sediment, 
inordinate quantities of albumin, and the patient gives a history of incon- 
tinence of urine and repeated exacerbations of high temperature. Poly- 
uria is a most constant symptom of urinary tuberculosis. 

Gonorrheal cystitis is associated with evidences of infection of other 
portions of the genito-urinary tract, particularly the urethra, glands of 
Bartholin, cervix, and pelvic organs, which have preceded the vesical 
disease. The gonococcus can generally be found. 

A form of inflammation of the bladder, known as membranous cys- 
titis, is a condition in which there is more or less extensive exfoliation of 
the bladder-wall, as in pseudomembranous, gangrenous, croupous, or 
diphtheric inflammation. It is always secondary to overdistention of 
the bladder from retention of urine. The mucous membrane is anemic 
during distention, but upon the removal of the bladder contents it be- 
comes acutely congested and engorged with blood. It may be produced 
by any obstruction of the urethra. The most frequent causes are incar- 
ceration of a retroflexed gravid uterus, unilateral hematometra, fibroid 



324 GYNECOLOGY. 

and ovarian tumors deeply seated in the pelvis, and loss of muscle power 
in low fevers and in septic conditions. 

The nurse or attendant may be led by the incontinence to overlook 
the occasionally enormous distention. The enlargement is gradual, 
extending above the navel, in the form of a tumor, which may very readily 
be mistaken for an ovarian cyst. The distention reaches its maximum 
when the reservoir can retain no more, and the abdominal pressure pro- 
duces an involuntary discharge of the overflow, a condition which has 
been spoken of as incontinence of retention. 

Even though the bedding is constantly soaked with urine, the bladder 
is never completely emptied. The continuous pain, involuntary dis- 
charge of urine, a suddenly formed, gradually increasing tumor, per- 
cussion dulness over its site, "absence of the uterus above the symphysis, 
and the projection backward of the anterior vaginal wall, should make 
the diagnosis plain. Constant dribbling of urine should always awaken 
suspicion of such a condition. 

Catheterization of such a patient by an ignorant midwife may cause 
the formation of a false passage, or negligence in the previous cleansing 
of the vulva will favor the entrance of infective agents into the bladder. 
No more favorable conditions for the extension of sepsis could be 
imagined. 

Even if cystitis did not exist, hyperemia, infection, and traumatism, 
as a result of retention, would not be surprising. The enormous dis- 
tention of the bladder causes anemia of its mucous membrane, thus pro- 
ducing disturbance of nutrition and superficial necrosis. Deep necrosis 
is caused by bacterial action. All such processes favor destruction of 
the mucous membrane. The inner wall of the bladder may become 
partially or completely detached, covered with phosphates of ammonium 
and magnesium, and penetrated with putrescent bacteria. The surface 
of the membrane is black or gray, contains numerous excavations, and 
sometimes horny concretions. The mucous membrane may come 
away in pieces or as a complete cast of the bladder. 

A portion of the membrane or the entire structure may lodge in front 
of the urethral orifice and completely obstruct the evacuation of urine. 
A small quantity of pus only may reward the introduction of the catheter. 
This pus has accumulated at the lower portion of the bladder, but a 
more forcible pressure of the catheter may cause it to penetrate the mem- 
brane and permit the evacuation of the decomposing urine. Violent 
tenesmus is a frequent symptom of such conditions. The urethra, 
dilated, will often permit the expulsion of the entire sac as a black, putrid 
mass. Cases have been reported in which complete exfoliation has 
taken place and the patient subsequently recovered good health without 
disturbance of the vesical functions. Neoplasms are differentiated from 
cystitis by the early appearance of hematuria, with absence of pain, 
tenesmus, or frequent micturition. 

The quantity of blood increases near the close of micturition; it may 
continue for days or weeks, and may cease suddenly. Sometimes frag- 
ments of the growth may be discharged. Hematuria dependent upon 



INFLAMMATIONS. 325 

tumors varies with their character. If the growth is benign, its progress 
is slow, unless the pelvis of the kidney and ureters are involved. 

Cystitis due to the presence of foreign bodies, such as calculi, is char- 
acterized by severe pain, frequent micturition, violent expulsive efforts, 
and hematuria, after active exercise. In arriving at a correct diagnosis 
it must not be overlooked that very marked disturbance of the bladder 
may arise from the administration of various drugs, from the application 
of vesicants, especially cantharides. In such cases micturition is fre- 
quent and very painful, while tenesmus is maiked. The withdrawal of 
the irritating cause is followed by prompt relief. 

The prognosis of cystitis is necessarily uncertain, and must depend 
upon the duration and character of the disease, extent of involvement, 
complications, and carefulness of treatment. When the disease has 
existed for a long time, the inflammation has extended through the mucous 
surface, more or less involving the muscular coat and causing contrac- 
tion, distortion, and great thickening of the walls. It can be understood 
readily, therefore, that no treatment will restore the functionating power of 
such an organ. 

The prognosis is especially unfavorable when the disease has extended 
to the ureter, and especially to the pelvis of the kidney unless nephrectomy 
is practicable. Tubercular disease of the bladder also presents an un- 
favorable prospect for ultimate recovery", although I have seen most 
gratifying results after the removal of the oft'ending structures when the 
tuberculosis was secondary to disease in one kidney and ureter. The 
favorable results in all cases will depend largely upon the carefulness of 
the treatment and the degree of cooperation the physician can secure from 
his patient. 

Treatment. In inflammation of the bladder the aim should be, first, 
to remove or lessen its cause; second, to afford relief to pain; third, to im- 
prove the general condition of the patient. 

Prophylaxis. The first indication is met most completely by proph- 
ylaxis, which in all conditions dependent upon microbic invasion, de- 
mands immediate consideration. Disinfection of the body, of the sur- 
roundings, of the hands, and of the instruments is necessary. The old 
procedure of introducing the catheter by touch is reprehensible. In the 
puerperal woman artificial light may be necessary. The legs should be 
flexed strongly, the better to bring the vulva into view. A small vessel is 
placed between the limbs, or the patient may be placed upon a bed-pan, 
and a warm disinfectant fluid poured over the vulva, which may enable her 
to void the urine spontaneously. If unsuccessful, the vulva is sponged 
with a cotton tampon and an irrigation stream is directed upon the urethral 
orifice. Throwing a stream of hot water against the external meatus 
through a small nozzle (as a medicine dropper substituted for the ordi- 
nary nozzle) generally will be effective. If still unsuccessful, a catheter is 
taken from a disinfecting fluid and carefully introduced, to avoid pain. 
Occasionally there is resistance at the internal end of the urethra, which is 
not overcome without pain. Care should be exercised in the withdrawal 
of the instrument, as the mucous membrane may be sucked into the eye- 



326 GYNECOLOGY. 

let of the catheter. Pushing up the instrument before its withdrawal will 
loosen it, when it can be removed without vesical injury. Whenever 
possible, the use of the catheter should be avoided, as, notwithstanding 
all precautions, the mucous membrane of the urethra will be irritated by 
its frequent introduction, thus affording an opportunity for infection. 

Medical treatment to a limited degree meets all the indications we have 
assigned for the treatment of cystitis. The acidity and tendency of the 
urine toward decomposition are combated by the use of diuretics and by 
the administration of large quantities of the alkaline waters, such as 
Saratoga, Vichy, Seawright, Buffalo or Londonderry lithia, Carlsbad, or 
Seltzer. The salicylates are among the most efficacious remedies. Salol, 

2 to 3 grains, can be given every three or four hours; strontium salicylate, 

3 to 4 grains four times daily. Some of the formalin compounds have 
been found very effective, as uro tropin, 5 to 10 grains, four times daily. 
Helmitol gr. x three or four times daily has the advantage over urotropin 
in that it can be given effectively in either acid or alkaline urine. These 
drugs should be administered largely diluted. They prevent decomposi- 
tion, remove the odor, and decrease pain and tenesmus. They should 
not be given on an empty stomach. The diet, though nutritious, should 
exclude stimulants, acids, and condiments, except salt. Sugars and 
starches should be sparingly used, and in acute and severe cases it is well 
to restrict the patient to skimmed milk. In acute cases the patient should 
be confined to bed, and all exposure to dampness or cold should be avoided. 
In all cases care should be exercised regarding suitable clothing and pro- 
tection against exposure. Pain may be so marked and micturition so 
frequent that measures must be instituted for its relief. Morphin or 
opium affords relief, but the pain soon returns. The remedy cannot be 
repeated every two or three hours without danger of establishing the 
habit. An ice-bag over the bladder will frequently give comfort; in other 
cases the hotwater bag is better borne. 

In the more distressing cases opium may be given in combination with 
belladonna or stramonium — tincture opii deod., gtt. x-xv; tincture of 
belladonna, gtt. iij-v every two or three hours until relief; or suppositories 
of extract of opium, 1/4-1/2 of a grain, and extract of belladonna, 1/8- 
1/4 of a grain, in cacao-butter — two, three, or four of these suppositories 
daily, according to the degree of pain. Relief is most quickly secured, 
however, by a hypodermatic injection of 1/6 of a grain of morphin with 
1/120 of a grain of atropin sulphate. When opium is badly borne, cocain 
hydrochlorid, 1/6 of a grain, may be given in suppositories in combination 
with the same quantity of extract of hyoscyamus. When the pain is 
limited to the urethra, it may be overcome by injecting 30 minims of a 
two per cent, solution of cocain with 5 minims of solution (i : 1000) adrena- 
lin chlorid through a syringe with a bulb nozzle. The openings about the 
bulb should be so situated as to direct the current back toward the external 
orifice. A celluloid syringe is preferable to a metal one because it can be 
used for sublimate and silver nitrate solutions. 

Inflammation of the neck of the bladder may be alleviated by the intro- 
duction, night and morning, of a vaginal tampon covered with an ointment 



INFLAMMATIONS. 327 

containing 30 grains of extract of belladonna to i ounce of camphorated 
lanolin. 

Calculi and foreign bodies should be removed and shreds of membrane 
and casts of the bladder should be separated early and evacuated. 

Gonorrheal and acute cystitis are often ameliorated by the administration 
of balsams, as copaibae, cubebs, or sandalwood oil; or when the urine is 
acid and scanty, the diuretics, such as the alkaline salts alone or in combi- 
nation with oil of birch, buchu, or triticum repens. The following pre- 
scription is often serviceable: 

R. Ammon. benzoat., oiij — or 

Tinct. hyoscyami, f o j-ij 

Ext. buchu vel tritici repens, ad f 3ij. M. 

SiG. — A teaspoonful in an ounce of water four times daily. 

Marsh directs: 

I^. Acid, oxalic, gr. xvj 

Syr. aurant. cort., f 5J 

Aq. pluv., ad fsiv. M. 

SiG. — A teaspoonful every four hours. 

When the urine is alkaline, benzoic acid, gr. x, in capsules may be 
given three or four times daily, directing the patient to take large draughts 
of some bland water. Benzoic acid, gr. x, or camphoric acid, gr. xv, may 
be given three or four times daily with great relief. 

The bromid salts are often of value. 

Free evacuation of the bowels by salines should be secured. After 
the severe distress and pain have subsided in acute cases and in all 
chronic inflammations advantage may be secured from intravesical 
medication. 

Indeed, even in the acute stages, irrigation of the bladder with hot 
salt solution frequently will relieve the distress. The bladder is irrigated 
through a return-current catheter by means of a fountain syringe: the 
fluid may be permitted to flow in until the discomfort is marked, when the 
tube is pinched and the fluid evacuated. (Fig. 312.) In the absence 
of a double catheter a single instrument may be used. The bladder is 
filled and the fluid is allowed to flow out, and the process is repeated until 
the bladder has been filled and emptied a number of times. This pro- 
cedure, practised once or twice daily, gradually distends a contracted 
bladder and diminishes its irritabflity. The irrigation fluid may be hot 
normal salt solution; boric acid, 3ij~i^'' to water, Oij; or methyl-blue 
(pyoktanin) , gr. xv, to water, Oiss, night and morning. If the urine con- 
tains pus, employ a 2 per cent, solution of ichthyol five or six times daily; 
the strength may be gradually increased to five per cent, after subsidence 
of acute symptoms. The strength of the solution at the beginning should 
not exceed one-half of one per cent. S. D. Powell advocates irrigation of 
the bladder with a solution of carbolic acid i : 30, followed by irrigation 
with alcohol; subsequently a 2 per cent, solution of the carbolic acid is 
employed. Protargol i to 10 per cent, mercurol 2 per cent, (zinc acetate 
and aluminol 1:4), are also highly extolled. Lutaud advocates throwing 



328 GYNECOLOGY. 

into the bladder, after irrigation with a boric-acid solution, four ounces of 
tepid water, to which is added a teaspoonful of the following emulsion : 

I^. Iodoform., o j 

Glycerin., 5x 

. Aq. destil., 5v 

Tragacanth., gr. iv. M. 

This preparation should be introduced and permitted to remain. 
In necrotic and suppurative cases cleanliness is of prime importance. 
The bladder should be irrigated repeatedly. The frequent ichthyol irriga- 
tion is rapidly curative. Irrigation with 3 to 5 per cent, solutions of resorcin 
or with silver citrate (1:8000 to 1:4000) has been advocated. I have 
found great improvement following the injection of one to two drams of 
a 10 to 20 per cent, solution of argyrol into the bladder allowing it to re- 
main. In tuberculosis and chronic cystitis the daily injection of 15-25 
minims of 5 to 20 per cent, solutions of guaiacol in sterile olive oil has b6en 
advised. 

Guyon advocated instillation of gt. xxx-xl of i : 5000 sublimate solu- 
tion, and as tolerance is secured, an increase from 1:5000 to 1:1500. 
Keisel used successfully alternate instillations of sublimate and creosote. 
Luys preferred emulsion of iodoform and guaiacol in vaselin oil : 

I^. Iodoform., gr. j 

Guaiacol., gr- v 

Vaselin oil., gr. c M. 

Instillation of 5 centimeters daily, without prior irrigation, and re- 
tained as long as possible. 

Pyrogallic, lactic, and carbolic acids are similarly used. Roosing 
especially commends the latter, having had thirteen cures by daily in- 
jections of 50 centimeters of a warm 6 per cent, solution retained 4-5 
minutes. It flows back milky, and the procedure is repeated until it re- 
turns clear. 

The cavity of the bladder may be explored by dilating the urethra and 
introducing one of the vesical tubular specula used by Kelly. With a 




Fig. 

good light the cavity can be carefully inspected and applications, such as 
silver nitrate, gr. x-xxx, to aq. destillat., i$j, made directly to the affected 
area. In the use of these stronger applications touching the affected or 
ulcerated points with a solution should be followed by irrigation with a 
salt solution. 

In subacute and chronic cystitis Clark introduces a vesical balloon of 
thin rubber. This balloon is connected with a thicker rubber tube, pro- 



INFLAMMATIONS. 329 

vided with a cut-off valve. Before using, it is boiled in a boric-acid 
solution, and its surface is coated over with a mixture of gelatin and 
ichthyol, lo per cent., or bismuth and zinc, salicylic acid, or weak bi- 
chlorid. The mixture is melted and poured over the bag, which has been 
rolled in the shape of a suppository. With a slender pair of forceps the 
balloon is introduced through the speculum. It is then inflated by a bulb 
syringe, the number of bulb pressures required to fill it having been 
previously determined. The balloon remains in situ twenty minutes. 

Guyon, in bad cases, advises that the bladder should be irrigated 
under anesthesia with a solution of boric acid or sublimate (i :io,ooo) and 
curetted with a medium-sized curet. The finger in the vagina as a guide 
enables him to go over the base and sides, while the hand over the ab- 
domen aids in reaching the anterior surface; lastly, the urethra is scraped, 
the irrigation is repeated, and a self -retaining catheter is introduced and 
retained some fifteen or twenty days. 

It is preferable that this procedure be limited to cases of ulceration 
and that the ulcerated surface only, be curetted. Nitrate of silver fixed 
on a probe, or in strong solution can be applied with advantage to the 
surface of the curetted ulcer. The iodid of silver has been lauded for 
irrigation and instillation. 

Camero reports twenty-nine cases treated with curet and catheter, of 
which nineteen were successful. Le Clerc-Dauday follows curetting by 
irrigation with a solution of chlorid of iron, and later by instillation of a 
I per cent, solution of silver nitrate. In bad cases, vesical drainage is 
very important. It can be accomplished by the use of a catheter, a rope 
of gauze through the urethra, or preferably cystotomy. The latter places 
the bladder absolutely at rest. A sound or bougie is passed through the 
urethra and used to depress the anterior vaginal wall, while an incision is 
made through the septum. The vaginal and vesical surfaces are united 
by sutures to prevent the opening from closing. This procedure deprives 
the patient of control of the bladder contents, and requires the provision 
of an apparatus or receptacle for the urine. 

In septic conditions, where a large portion of the vesical mucosa has be- 
come necrotic, the removal of the gangrenous mass should be followed by 
irrigation of the bladder with boric-acid solution (4:100) or a formalin 
solution (1:5000). A graduated irrigator is preferably employed, and 
not more than three or four ounces should be injected at one time. This 
may be pressed out, and the fluid again allowed to flow in, repeating this 
twenty times. The irrigation should be performed four times daily. It 
is surprising in these cases of extensive septic inflammation to note the 
subsequent power to retain the urine. 

Ohlmacher reported a case of cystitis and pyelonephritis from colon 
bacillus infection which improved markedly under seven injections of the 
bacillus serum. 

239. Ureteritis is inflammation of the ureter, and may be acute or 
chronic. It generally begins in the mucous membrane, extending through 
the wall of the canal, so that the ureter presents the palpable sensation of a 
thick, rigid cord. 



330 GYNECOLOGY. 

Causes. The disease, according to Mann, is produced by a number of 
causes: first, injuries during parturition; second, from previous disease of 
the bladder; third, gonorrhea; fourth, suppuration in the pelvis of the kid- 
ney; fifth, pelvic disease, such as pelvic peritonitis, cellulitis, and tumors; 
sixth, abnormal conditions of the urine; seventh, tuberculosis, to which 
may be added an eighth— the passage of calculi. 

Acute ureteritis is often mistaken for intestinal colic, pain from renal 
strain, catarrhal appendicitis, or acute catarrhal salpingitis. The patient 
has a sudden attack of abdominal pain in which the distress is limited to, 
or more pronounced upon, one side, or but slight upon the other. The 
pain is intermittent, with frequent severe paroxysms. General abdominal 
tenderness is probably absent, while there is noticeable tenderness upon 
deep palpation upon the affected side. In the beginning this is more 
marked near the pelvis of the kidney. The site of most marked tenderness 
may be situated at McBurney's point. As the inflammation subsides the 
pain disappears, and may be recognized at a point an inch above Poupart's 
ligament. Originating in the back, it cannot be differentiated in the 
early stage from colic occasioned by renal strain. When complicated by 
intestinal disorder, it may be recognized by its characteristic progress 
from above downward, the appearance of vesico-ureteral tenderness, and 
the urinary disturbance. When occurring upon the right side, its symp- 
toms are sometimes attributed to appendicitis. The condition may 
terminate in recovery or may result in the chronic form. 

Chronic ureteritis is characterized by frequent desire to urinate, which 
is more marked while erect, especially when standing, and is not wholly 
relieved by retaining the recumbent posture. The patient is obliged to 
arise from one to many times a night; the discharge may or may not be 
painful. Frequently, the desire to evacuate the urine will be imperative, 
and the urine will gush forth before she can secure privacy. Occasionally 
she complains of bearing down, greatly increased by standing, which 
disappears after a few hours' rest in bed. Palpation may afford no sign, 
except a slightly thickened cord, or a rigid mass almost the size of the 
finger, pressure along which will cause a discharge of urine with such 
power as to drive it some distance from the urethral orifice. The necessity 
for a cystoscopic examination of the bladder will depend upon the severity 
of the attack; when attended with much pain, it should be made. An 
alteration of the vesical mucous membrane in and about the orifice of the 
ureter will be recognized. 

This alteration may vary from a slight eversion and gaping of the 
orifice to one in which the orifice is an oval opening upon the summit of a 
mound of angry-looking mucous membrane. The mucous membrane in 
the immediate vicinity may be normal, but is generally red and injected, 
even roughened and eroded. 

The urea is said to be decreased upon the affected side. 

The urine may be secured for examination by catheterizing the ureters 
or by the introduction of the Harris double catheter. (Fig. 96.) 

Treatment. General treatment consists in the careful regulation of the 
diet, from which should be excluded strawberries, asparagus, and stimu- 



INFLAMMATIONS. 33 1 

lants; tomatoes, onions, and cabbage should be used sparingly and with 
caution. The food should be largely albuminous, of which skimmed milk 
may often form its base with advantage. Large quantities of water, 
alkaline diuretics, or the alkaline waters are useful. In acute and sub- 
acute cc>nditions the patient is best in bed. The nutrition should be pro- 
moted by general massage. 

Local applications are advantageously made to the inflamed orifice of the 
ureter and to the eroded surface about it. A solution of silver nitrate 
(gr. x-xxx to f 5j) produces good results. It should be applied through a 
speculum directly to the affected surface, after which the bladder should 
be irrigated with a normal salt solution. 

When the inflammation of the canal is extensive, the disease may be 
treated by irrigation through a ureteral catheter. 

In tuberculous disease, which is generally secondary to disease of the 
kidney, the affected kidney (the other having been demonstrated to be 
healthy) should be extirpated, and with it the ureter. 

240. Vulvovaginitis is an inflammation of the vulva and vagina, 
most frequently found in young girls, and, in the great majority of cases is 
believed to owe its origin to the presence of the gonococcus. Robinson 
("Trans., Lond. Obst. Soc," Jan. 4, 1898), in fifty-four cases of vulvitis in 
children, mostly under five years of age, was able to find cocci in the 
pus-cells which corresponded to the gonococci in forty-one. It may also 
be induced by want of cleanliness, decomposition of the natural secretions, 
or the entrance of pin-worms where proper cleanliness after stool is 
neglected. The importance of the condition is too frequently underesti- 
mated. The infection can extend to the uterus or even the pelvic perito- 
neum, producing changes which condemn the individual to suffering all her 
menstrual life and often render her sterile. The principal symptoms are 
pruritus, painful micturition, and a profuse yellowish, watery discharge, 
which constantly soils the clothing of the child and keeps the vulva irritated. 
The intense pruritus may readily generate the habit of masturbation. 

The infection may be spread by the hands, towels, linen, and bath. 
In chfldren's asylums it is not uncommon to find large numbers of girls 
thus affected. 

The condition is frequently complicated by ophthalmia, peritonitis, 
and arthritis. 

Treatment should be energetic. In the acute stage it consists in rest 
in bed, a light diet, and free evacuation of the bowels. The urine should 
be rendered bland, and cold applications should also be employed. 
Severe pain and burning can be obviated by local applications of cocain, 
several hot sitz-baths, and careful irrigation two or three times daily. 

The patient should be isolated. As a measure of prophylaxis care 
should be exercised in the bathing of children in hospitals and asylums, 
using shower rather than tub baths. 

In irrigation, cocain may be applied first. This can be followed by 
alkaline or antiseptic agents, potassium permanganate (i : 4000 to i : 1000), 
silver nitrate (1:2000), protargol (0.5 to i per cent.), or a ten per cent, 
solution of argyrol. The irrigation should be made through a soft-rubber 



332 GYNECOLOGY. 

catheter introduced into the vagina. If the vagina does not drain well, the 
hymen should be stretched, to remove any obstruction. After irrigation, 
the parts should be dried and a mild ointment applied. The vulva should 
be covered with a sterile dressing, which should be burned upon removal. 
The child and her attendant should be impressed with the danger of carry- 
ing the infection to the eyes. 

241. Vaginitis, elytritis, or colpitis is an inflammation of the mu- 
cous membrane of the vagina. The mucous membrane of the vagina closely 
resembles the structure of the skin, having few, if any, submucous glands. 
It consists of connective tissue surmounted by papillas covered with several 
layers of squamous epithelium. A longitudinal ridge is formed upon the 
anterior wall, from which rugae, or folds, like the teeth of a comb, extend 
upon each side. This formation is less distinct upon the posterior wall. 
The central projections are known as the anterior and posterior columns. 
The former generally terminate below in a rounded protuberance, called 
the vaginal tubercle, situated immediately above the meatus urinarius. 
Sometimes the anterior column is divided by a furrow into two portions. 
The rugae aid in promoting sexual excitement, and probably contribute 
to vaginal enlargement during pregnancy and parturition. They dis- 
appear toward the upper part of the canal. The vagina receives its blood- 
supply from the vaginal, uterine, internal pudic, and vesical arteries — 
branches of the anterior division of the internal iliac. The vagina is sur- 
rounded by a venous network or plexus, which communicates with those of 
the vulva, bladder, rectum, uterus, and broad ligament, and finally 
empties into the internal iliac veins. 

The lymphatics of the lower fourth communicate with the superficial 
lymphatic glands; those of the upper three-fourths, with the internal iliac 
glands. 

The nerves are derived from the sympathetic, and form upon each side 

of the vagina a plexus which communicates with the inferior hypogastric. 

The arrangement of the epithelium and the absence of glands render 

the vagina much less vulnerable to infection than either the uterus or 

vulva. 

We have already referred to the normal secretions of the genital tract. 
Doderlein distinguished between the physiologic and pathologic secretions 
of the vagina. The former is markedly acid, dependent upon the presence 
of a bacillus which produces lactic acid. The latter may be feebly acid, 
neutral, or alkaline, and contain a variety of micro-organisms — saprophytic 
and pathogenic. Probably fifty per cent, of pregnant women have this 
pathologic secretion, in which germs flourish, and from which auto-infec- 
tion is possible. The demonstration of the truth of this assertion greatly 
simplifies the study of the processes of infection. 

The vaginal discharge becomes alkaline during the menstrual period, 
during the puerperium, and in many cases of leukorrhea — a condition 
which is more favorable for the growth of micro-organisms and the 
infection of the genital tract. Doderlein's assertion, however, does not 
correspond with the results of the researches of Menge, Kronig, and 
Walthard. 



INFLAMMATIONS. 333 

Kronig's investigations were confined to pregnant and puerperal 
women, and consequently are not a proper subject for consideration under 
gynecology further than to note his conclusion that the distinction between 
the physiologic and pathologic secretions is not determinable. He asserts 
that all secretions alike contain no pathogenic germs. All secretions are 
equally germicidal, though the vitality of the germ differs. It takes twice 
the time to kill the staphylococcus that it does to destroy the streptococcus. 
The vagina infected with germs will become aseptic in two or three days. 
The cause of this bactericidal power is as yet undetermined. It is not 
chemic, because it occurs whether the secretion is faintly or strongly acid; 
it is not believed to be due to a special bacillus, although some micro- 
organisms are known to be antagonistic to others. If it results from leuko- 
cytes, it must be due to a property independent of their contractile power, 
for the action continues after their subjection to a heat which would de- 
stroy the latter. The want of oxygen in the vagina will not explain it, for 
the staphylococci and streptococci are anaerobic — i. e., grow independent 
of oxygen — and yet are killed. It is not mechanical, because particles of 
carbon and mercury are removed much more slowly. Possibly all these 
factors may unite to establish germicidal action. Kronig presents a very 
important practical observation, which is that a solution of corrosive 
sublimate for irrigation destroys the germicidal action, probably by pre- 
cipitation of albumin, while plain water but lessens it. A necessary in- 
ference is that prophylactic injections of corrosive sublimate are prej- 
udicial when the secretion is normal. Menge, in his investigations upon 
the nonpuerperal, introduced pyogenic micro-organisms into the vagina 
in eight women, and found that the vagina cleansed itself from these organ- 
isms in periods varying from two and one-half hours to three days. The 
factors which compass this germicidal action are various forms of bacteria 
and their products, an acid secretion, possibly serum action, and the 
absence of oxygen. This activity is weak in infants, is lessened by men- 
struation and by increased secretion from either the cervix or the body 
of the uterus, or even from the vagina. It is decreased when the vulva is 
patulous or the uterus prolapsed, and at the menopause. 

Walthard has directed attention to the influence of change of pabulum 
in restoring the lost virulence of micro-organisms. He inoculated the 
streptococcus into the ear of a rabbit without unfavorable results, unless 
the ear was ligated to lessen tissue resistance, when a streptococcus from 
the vagina became as virulent as those found in puerperal fever. It is 
possible that an innocuous streptococcus may thus be restored by the 
tissues during the puerperium, and similarly in gynecologic operations in 
which there is bruising of all the tissues, as in the enucleation of fibroids. 

Varieties. Vaginitis may be divided into simple and specific (gonor- 
rheal). The latter is exceedingly important because of its intractability 
and its tendency to extend. The distinction between acute and chronic is 
merely one of degree. Special varieties named are emphysematous, 
exfoliative, dysenteric, phlegmonous, diphtheric, and senile, but these are 
unnecessary distinctions. 

The etiology and pathology have undergone some consideration in our 



334 GYNECOLOGY. 

discussion of the action of micro-organisms. Of these, the gonococcus is 
most important, for upon its discovery will frequently depend the diagno- 
sis. It was discovered and described by Neisser. The recognition of its 
presence in the secretion is diagnostic, but its absence cannot be considered 
a positive indication that the secretion is of other than gonorrheal origin. 

Pathology. In simple vaginitis slight elevations of the mucous mem- 
brane occur, producing a granular surface. The granulations are pro- 
duced by groups of papillae, which are infiltrated with small cells; as a 
consequence, the papillae swell up and push before them the stratified 
squamous epithelium. Superficial layers are shed. Later, the surface 
becomes more level, from thinning of the superficial covering. With the 
vaginitis of pregnancy not infrequently an emphysematous condition of 
the mucous membrane is associated. These elevations have been de- 
scribed as cysts containing a gaseous fluid. The gas consists of air and 
trimethylamin. Ruge says the gas is situated in the cellular tissue, Zweifel 
says the masses are vaginal glands whose ducts have become closed. A 
similar condition has been observed following the climacteric. The 
exfoliative, dysenteric, or diphtheric vaginitis presents localized patches or 
an inflammation of the whole vagina. In the latter condition the mucous 
membrane becomes so swollen that it is with difficulty the finger can reach 
the cervix, which is also thickened and covered with an exudation. 

Senile Vaginitis. After the menopause the epithelial tissue is des- 
quamated, the papillae atrophy, and the raw surfaces cause obliteration of 
a large portion of the vagina. It often causes curious constrictions of the 
upper vagina, rendering the canal frequently cone-shaped, with the small 
end above, and disclosing the cervical opening as a mere dimple. Bands 
are often seen of contracting scar tissue which divide the vagina into 
loculi. Desquamation of the epithelium occurs. This probably is pro- 
duced by defective nutrition, and, later, granulations develop. A loss of 
elastic tissue also occurs, with an increase of connective tissue, which 
results in cicatricial contraction. The same process can cause occlusion 
of the cervical canal subsequent to the menopause. 

Specific Vaginitis. The most important cause of vaginal inflammation 
is gonorrheal infection. This produces an intractable form of vaginitis, 
which may continue for months, or even for years. It may extend over 
the mucous membrane of the uterus to the tubes, ovaries, and peritoneum, 
producing endometritis, salpingitis, pyosalpinx, ovaritis, and pelvic 
peritonitis. 

Etiology. Vaginitis is produced by gonorrheal infection; irritating 
discharges from the uterus; the contents of perivaginal abscesses; the 
contact of urine or feces from fistulae; vaginal injections, too hot or too 
cold, or those containing injurious chemic agents; badly fitting pessaries; 
decomposing tampons; efforts to produce abortion or awkward attempts 
at sexual intercourse; and the exanthemata; and it may complicate typhus 
fever, smallpox, and scarlet fever. Diphtheric patches have been observed 
in a number of diseases, particularly in the puerperal state. Localized 
patches are seen in fistulae, in carcinoma, and about badly fitting pessaries. 
The disease is induced by the habits of the patient. The free use of alcohol 



INFLAMMATIONS. 335 

produces the granular form of the disease. The gouty or rheumatic 
diathesis is a predisposing cause. 

Symptoms. Vaginitis is characterized by a sensation of burning, heat, 
and itching in the vagina; pain in the pelvic floor, increased by exercise; 
frequent desire to evacuate urine, frequently with scalding. A profuse 
mucopurulent leukorrhea soon occurs. These symptoms are present in 
both the simple and specific varieties. In the latter the disease begins as 
an acute infection within from twenty-four to forty-eight hours after 
exposure, with itching of the urethral orifice, increased desire to urinate, 
a sensation of heat about the \ailva, and burning and scalding upon passing 
urine. Generally, the tenderness and discharge are moderate; occasion- 
ally, throbbing is substituted. The distress is increased by walking, even 
by moving the limbs, and by the slightest touch of the finger. The 
urethral orifice is reddened and slightly swollen, and a drop of thick 
mucus or mucopus can be pressed out. After one or two days the en- 
tire urethra is exquisitely tender, and the orifice is swollen, intensely red, 
and bathed abundantly with pus. Pus and blood can be extruded from 
the vagina by pressure over the urethra. The hymen, vestibule, and labia 
become swollen, edematous, and eroded, and are covered with pus and 
exudate. At the end of a week the acute symptoms have subsided, the 
discharge is abundant, and when the parts are neglected, they become 
eczematous and cause a disagreeable odor. The vulva may regain its 
normal appearance in two weeks, while the discharge may continue for 
three or four weeks, or even longer. Infection of the vaginal follicles and 
of the vulvovaginal glands is frequent. The inguinal lymphatics become 
swollen, and may even suppurate. In the early part of the attack the 
gonococci are present to the exclusion of all other forms of bacteria, but 
later they may entirely disappear. The disease shows a marked tendency 
to invade the deeper and more important organs by the continuous mucous 
membrane. 

Diagnosis. Upon separation of the labia a profuse discharge is 
noticed, covering a reddened, thickened, and roughened or granular 
mucous membrane. The speculum reveals the vaginal mucous membrane 
as a red, swollen, smooth, velvety surface, from which the rugae have 
disappeared; or the redness, as well as the discharge, may be present only 
in patches. The cervix should be inspected, as the infection generally 
begins in it. The differential diagnosis between simple and specific 
vaginitis is often difficult. The history of a distinct infection would be 
valuable, but it is often too delicate a subject for' interrogation. It may 
be suspected from the sudden onset of the attack, associated with urinary 
symptoms, a protracted course, and obstinate resistance to treatment. 
The inflamed urethra and ducts of the vestibule and the orifice of Bartho- 
lin's ducts, and not infrequently, the formation of cysts or abscesses in 
the ducts or glands, with swelling of inguinal glands, afford additional 
confirmation. Recognition of the gonococcus by culture and micro- 
scopic investigation renders diagnosis certain. Absence of the gonococ- 
cus is not proof positive of nongonorrheal origin, for the gonococcus may 
disappear from the secretion. 



336 GYNECOLOGY. 

Even when the specific origin can be determined beyond peradventure, 
caution should be exercised in the expression of an opinion, as it may 
cause serious social unhappiness. The diagnosis of simple vaginitis will 
not be sufficient, but the physician should examine the various structures 
carefully to determine, if possible, the exact cause. Pelvic abscesses 
discharging into the vagina have been mistaken for vaginitis. 

Prognosis. The ease and rapidity with which vaginitis can be cured 
will depend upon the cause. The milder cases may be confined to the 
external genitalia, or may disappear even after the Fallopian tubes have 
become affected. In the more severe forms the entire genital tract may 
be involved rapidly, and portions of the tract may retain the disease and 
reinfect other portions. The general health is impaired in the chronic 
cases. The ovum, when it can enter, may find the uterus unfitted for its 
retention and, therefore, an abortion may result. Preexisting gonorrhea 
is said not to disturb the first two weeks of the puerperium, but subsequently 
there is a marked tendency for the germs to develop renewed virulence 
and to invade the healthy structure. 

Treatment. When the disease is in its acute stage, the patient should 
be kept absolutely quiet in bed. Sexual activity should be suspended, as 
well for the interests of the patient as for the prevention of further 
propagation of the disease. The diet should be confined to nonstimulating 
articles. Alcoholic stimulants, pepper, and various other condiments 
should be prohibited. Saline laxatives are advisable, and the patient 
should be encouraged to drink largely of emollient liquids or alkaline 
waters. 

Local applications should consist of hot sitz-baths, alkaline douches. 
A saturated solution of boric acid in hot water may be given for fifteen to 
twenty minutes out of every two or three hours during the day, and every 
four while the patient is recumbent at night. The ordinary fountain 
syringe serves well, or a piece of rubber tubing weighted at one end and 
provided with a clip and nozzle at the other. The weighted end, with the 
coiled tube, is placed in a basin of water above the level of the bed, the 
clamp applied, and the end of the tube withdrawn and introduced into the 
vagina. The clip opened, the water is siphoned out as long as the ex- 
ternal end is kept below the level of the basin. When the acute symptoms 
have subsided, douches should be given every three hours for the first two 
weeks. These douches may consist of solutions of sublimate 1:4000, 
potassium permanganate 1:4000, carbolic acid, lysol, or creolin, pro- 
targol 0.5 to I per cent., mercurol 2 per cent., sodium chlorid 2 per cent., 
or sodium bicarbonate 2 per cent. After the period mentioned the strength 
of the fluid may be doubled and the frequency of the applications is less- 
ened, now employing them four times daily. The dry treatment consists 
in cleansing the surface with a douche or by washing the vagina through a 
speculum; dry and pack with borated or iodoform cotton or gauze and 
repeat every eight hours until the secretion is checked, after which it is 
given twice daily. A dry absorbent dressing must be applied to the vagina 
every two hours. 

Astringent douches are substituted in chronic cases and after the sub- 



CERVIX AND BODY OF UTERUS. 337 

sidence of the acute stage. Cleanse and dry the vaginal walls and paint 
with silver nitrate solution (3j-f Sj)? followed by a tampon saturated with 
a solution of bismuth in glycerin, which keeps the walls separated. 
Fritsch recommends zinc chlorid (gr. ij :f gj). A one per cent, solution of 
lead acetate, zinc sulphate or alum, potassium permanganate (1:2000), 
or painting the surface with undiluted tincture of iodin, are serviceable. 
Acceptable powders are equal parts of tannin and iodoform, bismuth 
subnitrate and chalk, or boric acid and acetanilid parts retained with 
a tampon. In senile vaginitis cleanse with a saturated boric-acid solu- 
tion. Tampons may be saturated with a 0.5 per cent, solution of 
lead acetate, or strips of lint may be saturated in a five per cent, 
solution of carbolic acid in glycerin or smeared with zinc ointment. 
Vaginal suppositories of tannin and iodoform, each five per cent.; zinc 
oxid, ten per cent.; or lead acetate, two per cent.; may be used. When 
the condition is chronic, spray through a speculum with a two per cent, 
solution of silver nitrate. The spray drives the medicine into the crypts 
and folds, and is far more effective than swabbing. I have derived more 
benefit from tampons anointed with ichthyol in lanolin (1:4); it causes a 
desquamation of the entire epithelium of the vagina and is destructive to 
the gonococcus. 

CERVIX AND BODY OF UTERUS. 

242. Inflammation of the Cervix and Body of the Uterus. — The 

classification of uterine inflammation has been and still is a difficult and 
perplexing problem. 

Various views have been presented. The existence of inflammation of 
the endometrium, except in acute conditions, has been denied. The so- 
called chronic inflammation is denominated catarrh and uterine congestion, 
and frequently is attributed to peri-uterine inflammation. This statement 
would seem a distinction without a difference, and results from failure 
to appreciate the varying character of inflammatory changes in different 
tissues. The continuous mucous membrane is exceedingly vulnerable 
to the possibilities of infection. The irritation thus produced results in 
the production of inflammation. Its violence and extent will depend upon 
the virulence of the poison and upon the resistance of the patient. It may 
vary from a slight inflammation which involves the cervix only to one 
which extends to the entire uterine cavity with infiltration of the sub- 
mucous structures; or it may become interstitial or parenchymatous. 
Frequently in virulent attacks it passes through the wall to its surface and 
causes perimetritis. In our early classification we spoke of metritis, in a 
sense of inflammation of the entire organ; when it predominates in the 
lining membrane, it is called endometritis. When involvement of the 
deeper structures occurs, it is known as parenchymatous or interstitial 
metritis, and as perimetritis if the peritoneum becomes involved. The 
latter condition is generally described as pelvic peritonitis, because, al- 
though inflammation can reach the peritoneum as described, it more 
frequently does so by the progress of the inflammation through the tubes, 



7,^8 GYNECOLOGY. 

and its extension to other structures than those immediately enveloping 
the uterus. 

The anatomical arrangement of the cervical mucous membrane makes 
evident why inflammation can be confined to the cervix, although in 
puerperal women it is very prone to extend to the body. 

The various classifications are based upon clinical phenomena, 
pathologic changes, and causal relations. The ideal classification is that 
of Doderlein, in two divisions: first, inflammation produced through the 
influence of micro-organisms; second, inflammation independent of their 
influence. The former is subdivided into: (a) septic and saprophytic; 
(b) gonorrheal; (c) tubercular; (d) syphilitic; (e) diphtheric. The brevity 
of our knowledge of the influence of micro-organisms makes a careful 
differentiation difficult, but we are scarcely in a position to assert that there 
is any inflammation that is absolutely independent of bacterial production. 
My experience as a teacher has led me to discard the classification based 
upon the clinical phenomena, because it is difficult to associate therewith 
the pathologic relations. For this reason I propose to present the simpler 
and more frequently employed classification into acute and chronic, the 
latter subdivided into cervical catarrh, or endocervicitis, endometritis, 
and metritis. Acute endometritis affects both body and cervix. The 
chronic inflammation can be localized in the cervical mucous membrane. 
The classification of uterine diseases is still further complicated by the 
physiologic changes which occur in the uterus as a result of menstruation. 
Thus, the uterine mucosa undergoes a periodic hypertrophy and degener- 
ation, and it is often difficult to differentiate between the physiologic condi- 
tion and early pathologic processes. 

243. Endocervicitis — Chronic Cervical Catarrh. Cervical en- 
dometritis is an inflammatory process which affects not only the cervical 
canal, but the entire cervix. The symptoms and appearance of the 
disease differ greatly in the unmarried or nulliparous and the multipar- 
ous woman, and it manifests itself as inflammation of the portio vaginalis 
or of the cervical canal. In the former, the connective tissue of the 
vaginal portion of the cervix shows decided small-cell infiltration; the 
blood-vessels, especially the capillaries, become dilated and turgid with 
blood. Sometimes they become so distended as to form varicosities re- 
sembling hemorrhoids. Immediately beneath the epithelium the con- 
nective tissue is found rich in cells, which later become converted into 
granular tissue. The squamous epithelium of the surface is in many 
places infiltrated with leukocytes, and it undergoes hypertrophic changes 
from the increased blood-supply. Numerous papillae are formed and be- 
come covered with a single layer of epithelium which permits the red 
color to show through and the surface to present the appearance of an 
erosion. (Fig. 313.) Such a condition is generally recognized as simple 
erosion, and it generally involves the squamous epithelium of the vaginal 
portion of the cervix. When the external os has been lacerated, the lips 
often will be widely separated and gaping. The mucous membrane is 
everted and presents irregular granular patches which protrude beyond 
the OS. Such a condition was formerly regarded as ulceration. The 



CERVIX AND BODY OF UTERUS. 339 

microscopic examination of such a surface reveals the apparently denuded 
portion covered with epithelium. The increased blood-supply and the 
infiltration of the tissue with lymphoid cells cause the cervical lining to 
become everted and project from the os like a fungus. Such a reddened, 
everted surface is sometimes known as granular or papillary erosion. 
At first the glandular structure is not involved, but eventually hyperplasia 
of the glandular epithelium results and there is an increase in the number 
and size of the glands. (Fig. 314.) The latter condition is more limited 
to the superficial structure, which seems to be taken up with glandular 
tissue, to the almost complete exclusion of the connective. In the former, 
the glands enlarge and project through the structure of the cervix, some- 





FiG. 313. — Simple Papillary Erosion of Fig. 314. — Simple Papillary Erosion with 

the Cervix. Enlarged Follicles. 

times even lifting up the squamous layer. The accompanying hyper- 
plasia of the connective tissue may cause more or less constriction of the 
gland-ducts, and in certain places they may be closed completely, thus 
resulting in the distention of the glands and the formation of cysts. These 
cysts are known as retention cysts or ovules of Naboth. (Figs. 314 and 
315.) They form nodular projections around the external os or can pro- 
ject deeply into the cervical tissue, becoming prominent upon the vaginal 
surface at quite a distance from the external os. As the vaginal portion in 
the normal condition possesses no glands, it is evident these have been 
either extruded from the os with the hypertrophied mucous membrane, 
or have pushed through the structure of the cervix in the manner already 
described, and may lead to an extensive cystic degeneration of its struc- 
ture. In one patient recently under observation change in the structure 
of the cervix was so marked as to lead to the diagnosis of sarcoma by 
myself and others, but the subsequent investigation disclosed that the 
condition was benign, though the cervix was entirely taken up with the 
cystic change. Infection may result in the formation of abscesses, or 



340 



GYNECOLOGY. 



the gradual distention may lead to a rupture of the cyst, producing what 
is known as follicular erosion, in which the entire cervix or the greater 
portion of it may be involved. The increased glandular secretion, mixed 
with the transudation from the eroded surface, produces a very profuse 
leukorrheal discharge. The protruding structure often is so extensive 
as to render its origin uncertain, but evidently it is produced by prolifer- 
ation of the epithelial lining of the cervical glands. Chronic inflamma- 
tion of the connective tissue occasionally causes such hyperplasia as to 
increase the size of the cervix greatly. In the nulliparous the cervix 




Fig. 315. — Extensive Cystic Disease of the Cervix. 
a, a. Glands dilated with secretion, b. Large nodule formed by union of many glands and 

distended with fluid, 



forms either a rounded mass, which increases its size in all directions, or 
may become so elongated as to produce a condition resembling prolapsus, 
known as pseudoprolapsus. In previous laceration of the cervix only 
one lip may have undergone this hyperplasia. Both lips may be involved 
when they will be widely everted and turned outward and backward , 
reminding ane of the top of a celery stalk. The glands over such a sur- 
face are likely to become obstructed and produce retention cysts, which 
are recognized as firm, pea-like masses beneath the finger. Occasionally 
such cysts form abscesses or rupture, and with the proliferating epithe- 



CERVIX AND BODY OF UTERUS. 



)4I 



Hum present an extensive raw surface which can be mistaken for carcinoma. 
A number of cysts in close approximation may become united through the 
absorption and breaking-down of the interv^ening septa and thus form 
one large cyst. Puncture of the cyst permits the escape of a large quantity 
of viscid fluid rich in corpuscles, with subsequent contraction and obliter- 
ation of the cavity. 

From the discussion it can be readily inferred that the inflammation 
involves all the structures of the cervix, the epithelium, the glands, and 
the connective tissue, and thus varies in its form and manifestations ac- 
cording to the predominance of the structure involved. When the glands 
are extensively involved, the cervix presents w^hat is know^n as cystic de- 







^^0^^ 









mmm 









Fig. 316. — Chronic Endocervicitis. 
a. Dilated gland forming cyst of Naboth. h. Detachment of glandular epithelium after 

absorption of fluid. 



generation. The increase of connective tissue results in what Thomas 
has so aptly described as areolar hyperplasia or cervical sclerosis. 

Causes. Inflammation of the cervix arises from extension of inflam- 
mation from the body of the uterus, the vagina, and the vulva, as a result 
of excessive coition, laceration, injuries during instrumental and digital 
examination and manipulation, and from puerperal and gonorrheal in- 
fection. The cylindrical lining of the cervix is particularly vulnerable 
to infection, especially after laceration, when exposed to friction against 
the walls of the vagina, and to injury during the act of coition or examina- 
tion. It is rare to have inflammation of the body of the uterus without 
involvement of the cervix. The latter is prone to occur because the uter- 
ine discharges flow over the cervical mucous membrane and irritate it. 
Endocervicitis is particularly likely to be produced by congestion of the 



342 GYNECOLOGY. 

uterus in association with flexions, especially retroflexion. In retrodis- 
placements and in anteflexion separation of the lacerated surfaces is 
favored, and the deUcate cervical mucous membrane is exposed to a 
greater degree. 

Symptoms. The principal symptoms of cervical inflammation are 
leukorrhea, pain in the back and loins, aggravated by exercise or stand- 
ing, irregular menstruation, and sterility. Leukorrhea is the most im- 
portant symptom. The normal secretion from these parts is insufficient 
to attract attention. When it is excessive, it becomes known as leukor- 
rhea, or, in popular language, the whites. A temporary discharge — a 
transparent leukorrhea, like white of tgg — due to temporary congestion 
frequently occurs preceding and following the menstruation. The 
secretion from the cervical glands is clear and viscid, resembling white 
of egg. It becomes white when mixed with mucus-corpuscles, and yellow- 
ish when pus-corpuscles are present. Not infrequently it is tinged with 
blood, which escapes from the delicate vessels of the newly formed vascu- 
lar tissue. Pain is aggravated by walking, standing, riding, or anything 
which increases the friction between the cervix and the vaginal walls. 
Menstruation is irregular and there is generally an increase in the quantity 
of the flow, probably produced by an extension of the inflammation to 
the endometrium. Sterility is often present. In the nulliparous woman 
suffering from endometritis the cervical canal is filled by a plug of mucus, 
which may afford a bar to conception. In the multiparous woman the 
presence of cervical inflammation may render the woman less susceptible 
to pregnancy, but it is not, however, considered an absolute obstacle to 
conception. 

Physical Signs. The appearance and outline of the cervix differ in 
the nulliparous and multiparous woman. In the former it is puffy 
and large, the os being soft and velvety. The patient will complain of 
pain when the cervix is moved or pressed. In the multipara the cervix 
is generally lacerated; its margins are soft, velvety, and eroded, or hard, 
presenting pea-like nodules, polypoid projections, cystic masses; or the 
OS may be gaping, so as to permit the introduction of the finger nearly 
to the internal os. The one lip may have undergone involution, while 
the other is enlarged and elongated. The mucous membrane is irregu- 
lar, not infrequently presenting longitudinal ridges. Digital examination 
affords an idea as to the position and relation of the cervix, and as to its 
condition, whether lacerated or otherwise. The digital examination 
should be supplemented by the use of the speculum, the latter being used 
to confirm suspicions which have been engendered by the digital exami- 
nation. The Sims speculum is preferable, as it affords less displacement 
to the parts and permits more thorough and complete inspection. In 
the nullipara the os will be filled with a plug of tenacious mucus sur- 
rounded by a patch of excoriated tissue, particularly upon the posterior 
lip, from which the outer layers of the epithelium have been desquamated. 
In the multipara probably a laceration will be seen. Its presence is often 
overlooked, because the fissures are filled up with indurated cicatricial 
tissue. The use of tenacula to turn in the surfaces demonstrates its 



CERVIX AND BODY OF UTERUS. 343 

existence. The bluish-red ovula Nabothi may be readily seen as nodu- 
lar projections upon the surface. 

Diagnosis. Cervical catarrh is readily determined from vaginal 
inflammation by the use of the speculum. In the former a plug of mucus 
will fill up the cervical canal and project from it, being so viscid and 
tenacious that its removal is accomplished only with difficulty. To 
remove the mucus thoroughly from the surface it may be necessary to 
use a curet or better, suction by a syringe. The mucus in the interior 
of the dilated glands should be removed by puncture and digital pressure. 
When the cervical discharge is insufficient to render it visible, Schultze's 
method may be employed. He gives the patient a vaginal douche, in- 
troduces a speculum, thoroughly cleanses the surface, and places a tam- 
pon soaked with a solution of tannin against the external os. This ap- 
plied at night and removed through a speculum the following morning, 
the character and quantity of the discharge from the cervix can be noted. 

The differentiation between endocervicitis and endometritis is still more 
difficult. In many cases, indeed, we may not be able to say definitely 
that a cervical catarrh is not associated with more or less inflammation of 
the endometrium. The enlargement and thickening of the cervix dem- 
onstrate that it is the seat of inflammation. It is sometimes difficult to 
differentiate between inflammation and malignant disease of the cervix. 
In the former the hypertrophy is more general and uniform, the tissues 
are more or less firm, but not hard, and show no inclination to friability. 
In malignant disease the cervix at points may be hard and indurated from 
the presence of an infiltrate which is more or less localized. An exca- 
vated ulcer may be present, covered with friable, easily broken-down tissue, 
which will crumble and become detached under the finger, while the base 
is hard and resisting. Hemorrhage and a profuse, foul-smelling discharge 
are prominent symptoms. When the condition is such as to leave one 
in doubt, a test excision should be made and the excised tissue subjected 
to microscopic investigation. 

Prog7iosis. The curability of endocervicitis is dependent upon the 
general health of the patient, the duration of the disease, and the extent 
of involvement. Not infrequently it will be found that these patients 
have passed through the hands of a number of physicians, and, therefore, 
extreme care must be exercised as to the prognosis. The result is less 
favorable when there is a large amount of secretion and apparently but 
little glandular degeneration. 

Treatment is first, constitutional : The patient should be encouraged 
to take outdoor exercise. Frequently change of air will prove of decided 
value. Quinin, iron, strychnin, arsenic, and the bitter tonics, will be 
of advantage. Indigestion should be corrected, regular action of the 
bowels secured, and sexual rest advised. 

Second, local treatment: In the nullipara it is advisable to give hot 
vaginal douches through a fountain syringe under moderate pressure for 
ten to fifteen minutes each night, having the patient preferably in the re- 
cumbent position. Doubtless in some cases the hot water thrown with 
force from a bulb syringe against the cervix will have a more marked 



344 



GYNECOLOGY. 




Fig. 317. 



-Lines of Incision for Contracted or 
Pinhole Os. 



modifying influence upon the hyperplastic process and, therefore, it 
should supplant the fountain syringe. The temperature of the water 
should be from 110° to 115° F., and the patient should be advised to re- 
main in bed following the douche. Astringents can be added, such as 

a solution of zinc sulphate 
(3j-ij-water Oij), powdered 
alum (3j-0ij), lead acetate 
(3j-ij-0ij), or the latter and 
zinc sulphate may be com- 
bined. Mild solutions of 
antiseptics may be substi- 
tuted for the astringent, as 
hydrargyri bichlorid (i :40oo), 
formalin (1:2000), but these 
agents present no special ad- 
vantage over the douche of 
sodium chlorid, $j, water Oij. 
The OS, when narrow and 
contracted so that drainage is 
ineffective, should be notched 
bilaterally with scissors, to 
permit the escape of the 
mucus. The lips should be trimmed, making a funnel-shaped opening. 
(Figs. 317 and 318.) When the secretion continues, local applications, 
such as tincture of iodin or carbolic acid, a saturated solution of iodin 
crystals in carbolic acid, 95 per cent., can be employed; the former in 
mild, the latter in more severe, 
cases. Heywood Smith ad- 
vises acid nitrate of mercury; 
De Sinety, chromium trioxid. 
Better results are secured from 
the employment of the milder 
agents, as zinc sulphate or 
chlorid gr. x, aqua fgj, silver 
nitrate gr. x-xv-gj, or solu- 
tion of argyrol (20-40 per 
cent.). In making an appli- 
cation, the mucus should be 
removed first from the canal 
with a cotton-wrapped appli- 
cator, a pledget of gauze in 
dressing forceps, by suction 
with a long nozzled syringe, 
or a blunt curet. When the 
mucus is very- tenacious, its removal is greatly facilitated by throwing 
in a few drops of hydrogen dioxid by means of a pipet, after which 
it is more readily wiped away. This step is important to prevent the 
application from being coagulated by the mucus without reaching the 




Fig. 318. 



Union of Vaginal and Cervical Mucous 
Membranes. 



CERVIX AND BODY OF UTERUS. . . 345 

afifected surface. After the application any surplus fluid should be 
removed, and a tampon of cotton or of gauze saturated with glycerin 
should be placed beneath the cervix. A 25 per cent, solution of ichthyol 
in glycerin, or ichthyol in lanolin, of the same strength, may be applied 
to the cervical canal with a cotton-wrapped probe, or a small pledget 
of gauze or cotton anointed with it may be carried into the dilated cervix, 
or a tampon medicated with it may be applied to the eroded cervix. 
Ichthyol is advisable because of its germicidal action. The application 
of such a tampon will not infrequently result in the desquamation of 
an epithelial cast, followed by a regeneration of the epithelium and restor- 
ation of a healthy appearance of the cervix. The application of a satu- 
rated solution of iodoform in ether is advised. Ether stimulates con- 
traction of the glands and forces out the secretion, while the iodoform re- 
maining acts as an antiseptic. In the multipara, endocervicitis is not 
infrequently complicated by retroflexion, subinvolution, or laceration of 
the cervix. The first consideration should be to relieve congestion by 
scarification of the surface, puncture of retention cysts, hot astringent or 
antiseptic douches, and the use of medicated tampons. Some form of 
glycerin medication upon the tampon is especially efficacious in causing 
profuse depletion. The displacement should be corrected and the or- 
gan should be maintained in a proper position by a tampon or pessary. 
When the cervical mucous membrane is much everted and the lips are 
widely separated by laceration of the cervix, the relief of the engorge- 
ment and congestion can be overcome by Emmet's operation. The uterine 
congestion may be greatly decreased by local depletion through scari- 
fying or puncturing the cervix. Such depletion is of special value where 
a number of glands of Naboth have become obstructed and have formed 
retention cysts. Evacuation of the cysts and the introduction of tincture 
of iodin or carbolic acid into their cavities cause a sufficient amount of 
inflammation to obliterate them and relieve the pressure. In obstinately 
chronic cases destruction or removal of the diseased glandular tissue is 
imperative. It may be accomplished by the use of the Paquelin thermo- 
cautery or by various caustics. Skoldberg recommends zinc-alum sticks, 
which are made by running together into molds equal parts of zinc sul- 
phate and alum, forming a small stick, which is carried into the cervix 
and retained by a plug of gauze in the vagina, which also receives the dis- 
charge. Silver nitrate in solid stick was formerly much used for this 
purpose. The latter method of treatment is required only in exceedingly 
severe cases, and its application should be extremely limited. It cures 
by destruction of the mucous membrane and glandular structure, sub- 
stituting for them cicatricial tissue. It should not be used where there 
is danger of the cervical canal becoming so contracted as to interfere with 
drainage from the uterine cavity. Colpe, finding that an inflammation 
of the cervix did not yield to the use of astringents and caustics, examined 
the secretion and found present mycotic spores, after which he used lactic 
and salicylic acids, with immediate relief. 

Electricity has its advocates. The negative pole is introduced into 
the cervix, while the positive pole is placed upon the abdomen. It is 



346 GYNECOLOGY. 

questionable, however, whether this plan of treatment has any advantage 
over other caustic measures. The use of the sharp curet not only removes 
the glands from the cervical canal, but, as advocated by Thomas, scrapes 
away the arbor vitae from the internal to the external os. This measure 
not infrequently has to be repeated a second or even a third time before 
relief is complete. When there is very marked eversion or an eroded, 
deeply fissured surface, Schroder's operation should be performed. This 
consists in the formation of a single flap in each lip. The method of 
procedure has been described. (Section 208.) Franklin Martin re- 
moves a larger amount of the cervix, and combines amputation with ex- 
cision. He splits the cervix into two lips, cuts through the cervical mu- 
cous membrane on the posterior lip above the diseased portion, then re- 
moves as much of the lip as is necessary, and stitches it. The anterior 
lip is treated in the same way. 

244. Acute Metritis and Endometritis. In acute inflammation 
the pathologic changes are not confined to the endometrium, but rapidly 
involve the entire organ. In the nonpuerperal uterus they are excited 
by infection from gonorrhea; follow trauma, induced by exploratory op- 
erative procedures; or result from exacerbations of the chronic state. 
The nonpuerperal cases are rare and scarcely ever fatal or sufficiently 
threatening to require hysterectomy. Such an inflammation is generally 
brought on by an infection which has occurred during parturition or 
abortion, and, consequently, is more an obstetric than a gynecologic 
condition. 

Infection is favored by: 

1. Protracted labor during which the tissues have been subjected to 
bruising or laceration. 

2. Want of skill or cleanliness in the practice of manual or instru- 
mental procedures. 

3. Retention of clots, portions of placenta, or decidua after labor or 
abortion. 

4. Presence of septic germs in the genital canal prior to the occurrence 
of gestation, their introduction during the process of delivery or in the 
subsequent convalescence. 

Pathologic Alterations. The infection is implanted originally in the 
degenerated mucosa, in thrombi of the uterine sinuses, the site of the 
placenta, in retained portions of placenta or decidua, or in lacerations of 
the vagina or vulva. Intense hyperemia produces alterations in all the 
tissue elements. The gland lumina are dilated by increased secretion 
and proliferation of glandular epithelium. Round-cell infiltration oc- 
curs in the affected tissues with subsequent degeneration and destruction 
of their cellular elements. The mucosa becomes greatly swollen and 
edematous. Its epithelium is found granular and desquamating. The 
uterine blood-vessels and sinuses become engorged and thrombosed. 
Inflammatory exudate is poured into the cellular tissue which may re- 
sult in abscess formation, either in the walls, sinuses, or both. 

Such pus pockets, at first small and localized, increase in size, the 
intervening walls break down, and an abscess of considerable size may 



CERVIX AND BODY OF UTERUS. 347 

form, rupture into the uterine cavity, and thus terminate favorably. 
More frequently, a large portion of the uterus becomes gangrenous, 
causing a serious detriment to health — even loss of life. The autopsy 
on one of my patients who died in the Philadelphia General Hospital 
revealed the entire uterine fundus as completely destroyed. 

The infective processes are not confined to the uterus, but the infection 
travels by blood-vessels or the lymphatics to the parametrial tissue where 
the effort to limit its progress results in the formation of inflammatory 
exudate. This often fills the pelvis, encircles the uterus, and practically 
imbeds it. If the infection is virulent or the resistance of the patient 
greatly diminished, extensive pus collections occur. The walls of the 
blood-vessels become inflamed and phlebitis of the veins is a result. Frag- 
ments of infective material float in the blood to lodge in distant parts to 
form secondary collections and thus produce infarcts or abscesses 
according to its virulence. This condition, known as pyemia, is the prod- 
uct of the same micro-organisms that produce septicemia. The joints 
(particularly the knee and elbow), the lungs, liver, kidneys, heart, spleen, 
brain, and the skin may be the seat of these pyemic processes. 

Varieties and their Source. The manifestations of infection will de- 
pend on its character and are properly divided into the sapremic, septi- 
cemic, and the pyemic. 

Sapremic infection is the product of the action of saprophytes on re- 
tained blood clots and portions of the decidua or placenta, which result 
in their decomposition and the subsequent absorption of the toxins thus 
produced. While decomposed material undisturbed presents a favorable 
soil for the implantation of septic infection, septicemia occurs more 
frequently as a primary disorder induced by the entrance of the pathogenic 
germs through fractures of the mucous membrane of the uterine body, 
cervix, vagina, or vulva. It has already been indicated that inert path- 
ogenic micro-organisms inhabiting the vagina can be stimulated into 
activity by changed conditions, but are more frequently introduced from 
without, through failure of the physician or nurse to observe proper 
antiseptic or aseptic precautions. 

Pyemia is the result of the circulation in the blood of particles or 
fragments of infected material which can be carried to parts remote from 
its original location and result in the formation of additional and recur- 
ring foci of infection. It is dependent for its production on the same 
germs which result in the development of septicemia. 

Symptoms. Sapremia suddenly manifests itself, three to ten days 
subsequent to delivery, by elevated temperature and repeated rigors. 
Chills may occur daily, with a temperature varying from 102° to 105° F. 
though generally increased, and abdominal pain and tenderness are not 
marked. The lochial discharge may be absent, or exceedingly foul. 
Manipulation over the uterus may be followed by contraction and the 
expulsion of a large offensive mass, after which the patient will improve, 
or she may have profuse bleeding. Digital examination discloses the 
presence of retained masses and affords evidence of their decomposition. 
Septicemia is more insidious in its onset, but the symptoms appear earlier. 



34^ GYNECOLOGY. 

The reaction induced by septicemia will depend upon the condition of the 
patient, the length of time after delivery prior to infection, and the viru- 
lence of the infective poison. Its course naturally depends on the particu- 
lar structures involved. As early as the second or third day, not infre- 
quently upon the first, the patient will exhibit an elevation of tempera- 
ture, which gradually increases. She suffers from pain or tenderness 
in the lower abdomen, which may be so marked as to confine her to the 
dorsal decubitus, with her limbs flexed and unable to exercise the slight- 
est muscular action, because of pain. Not infrequently the bladder be- 
comes greatly distended; the pulse is rapid, varying from no to 140; 
respirations frequent, and the temperature displays a range from 101° 
to 107° F. The lochial discharge is arrested or free, and may be mucous, 
mucopurulent, ichorous, or sanguinolent. It may have a stale, sicken- 
ing smell or be almost free from odor. The cervix and vagina, upon 
inspection, may appear normal or highly inflamed, swollen, and covered 
with glairy mucus, or exhibit patches of diphtheric exudate. The entire 
uterine structure is likely to be smooth, swollen, and exceedingly tender 
to pressure. The cervix will appear lacerated and boggy. When the 
inflammation is confined to the uterus, the organ will be tender and en- 
larged, edematous and flabby, but not so sensitive as to preclude palpa- 
tion. If the peritoneum is involved, pain and tenderness will be very 
acute; the limbs are drawn up to protect the abdomen from pressure of 
the clothing and to relieve the traction upon the abdominal wall. The 
progress of the disease will depend upon the virulence of the poison and 
the resistance of the patient. In the sapremic condition the source of 
origin of the disease may be expelled and the patient rapidly progress 
toward recovery. A patient suffering from septicemia may be so for- 
tunate as to secure immunity against its further progress and slowly 
recover. The disease may become localized and a pus-collection be 
spontaneously or artificially evacuated, or the general system may become 
so infected that, notwithstanding every therapeutic procedure, the patient 
succumbs. An unfavorable prognosis is indicated by a persistent high 
temperature, a pulse-rate continuously above 130, and the absence of 
localized foci. If the serious symptoms subside and the general condition 
of the patient improves, but the pulse-rate continues rapid, with an even- 
ing temperature of 100° F. or over, the patient should be regarded as 
still in danger. Septicemia was formerly known as puerperal fever and 
was supposed to be due to some obscure poison characteristic of that 
condition. The investigations of Semmelweiss and others demonstrated 
that it was analogous to surgical fever and due to a similar cause. The 
disorder is hydra-headed in its manifestations, and makes its invasion 
by one of three routes: through the continuous mucous membrane of 
the body of the uterus and Fallopian tubes to the peritoneum; through the 
blood-vessels or the lymphatics. Thus we may have inflammation of 
the structure of the uterus, the Fallopian tubes, the ovaries, the pelvic 
cellular tissue, or the pelvic peritoneum, or even all combined. Any 
of the veins of the body may become involved in the septic phlebitis, 
but the condition occurs most frequently in those of the lower extremities, 



CERVIX AND BODY OF UTERUS. 349 

causing the condition formerly known as milk-leg, which we now recog- 
nize to be an infective phlebitis. It may manifest itself also by a severe 
lymphangitis. The disease may rapidly involve the general system, 
giving rise to profound symptoms of septicemia without any special local- 
ization. A stinking lochia has been regarded as affording a favorable 
prognosis. Septicemia may terminate fatally in twenty-four hours or 
the patient may continue in a serious condition for weeks and finally 
recover. 

Pyemia is slower in its manifestations. It may develop suddenly with 
a severe chill when the patient has manifested no alarming symptoms 
until the fifth to the eighth day. Without an indication of peritonitis 
or parametritis the temperature becomes high, the pulse-rate rapid, and 
the patient has recurring chills. These may occur at intervals of a day 
or not for several weeks. Death may occur in ten to fourteen days, or 
this disorder may continue for months. Abscesses may occur in the 
larger joints, the internal organs, and in the skin. 

Diagnosis. The early differentiation of sapremia and septicemia is 
very important. The former, being associated with retained decompos- 
ing products, manifests itself several days after delivery. Symptoms 
develop suddenly in a patient who seemed to be undergoing a normal 
convalescence. The lochial discharge, where present, is exceedingly 
offensive. A digital examination discloses a clot, a portion of placenta, 
or a portion of decomposing membrane within the uterine cavity. These 
products, when removed, have a very offensive odor, and with their dis- 
appearance the symptoms rapidly subside. In septicemia the symptoms 
occur more insidiously and at an earlier date following delivery, unless, 
however, the infection should have been implanted late. Elevation of 
temperature following a delivery should be regarded as a danger-signal, 
and induce the attendant to review the patient's history, and instigate a 
judicious interrogation of the physical signs. The condition of the 
breasts should not be overlooked for frequently women have a high 
temperature concomitant with the establishment of lactation. The 
breasts become greatly distended, caked, and hard. The temperature 
of the patient may reach 105° F. or over. Occasionally the nipples may 
be the source of infection and lead to mammary abscess. 

Typhoid fever and malaria are frequently mistaken for sepsis and 
vice versa. The possibility of these conditions should be excluded by a 
careful examination of the blood. Finding in malaria the plasmodium, 
in typhoid fever a positive Widal reaction, and the examination of the 
urine establish the diagnosis. Furthermore, the typhoid bacillus may 
be found in the urine and occasionally in the blood. A digital examina- 
tion excludes sapremia when it reveals the walls of the uterine cavity 
to be smooth and free from any decomposing products. Intoxication 
from morbid products in the intestinal tract sometimes may simulate 
septicemia closely. It was my privilege to see with two physicians a 
young woman who w^as suffering from a very high temperature with some 
abdominal distension. There were no signs of any localization of sepsis. 
The patient had been delivered a week previously. Examination dis- 



350 GYNECOLOGY. 

closed the uterine cavity to be free from any decomposing material. 
There was absence of tenderness over the uterus. The woman had some 
fifteen foul-smelling stools during the preceding twenty-four hours. It 
was her first confinement, and there was a history of her having under- 
gone a curetment some three years before. She had been very care- 
fully managed during her confinement, with every aseptic precaution, 
and had been cared for by a well-trained nurse. The inference of the 
attendants was that she had some local accumulation in a tube prior to 
her delivery, from which this infection had developed. But as I found 
the uterus free from any tenderness or undue enlargement, no sign of in- 
fection in the vagina, no tenderness nor swelling about either tube or 
ovary, I reasoned, therefore, that if a local condition had existed, it 
should still show evidence of its presence. In view of the very evident 
intestinal disturbance, I ascribed the symptoms to an intestinal infec- 
tion, and suggested measures for its correction. The rapid subsidence 
of the symptoms and recovery of the patient confirmed the diagnosis. 

Having reached a diagnosis in septicemia, by exclusion, it is desirable 
to recognize and treat the local manifestations promptly. These are 
determined by the size and evidence of laceration of the cervix, the exist- 
ence of patches of diphtheric exudation in the vagina or uterus, and the 
possible form and progress of the infection. Metritis will be indicated by 
a large, swollen, more or less tender and boggy uterus; perimetritis or 
pelvic peritonitis by extreme tenderness in the lower portion of the abdo- 
men, pain and anxiety of the patient, a frequent, rapid, wiry pulse, and 
high, sometimes low, and even subnormal, temperature; the latter symp- 
toms, moreover, rather increasing the danger. Phlebitis will be recog- 
nized by tenderness over the femoral and saphenous veins, as these are 
the ones in which the disease most frequently manifests itself. Lymphan- 
gitis is often indicated by the existence of inflammation of the cellular 
tissue and by pain and tenderness over the lumbar or inguinal 
regions. 

Pyemia is recognized by the occurrence of chill, or recurring chills, 
associated with a low grade of fever, frequent sweating — especially when 
accompanied by the evidence of inflammation and the formation of ab- 
scesses in different portions of the body. 

Prognosis. Sapremia usually terminates favorably. The removal 
of the putrid products favors subsidence of the constitutional intoxica- 
tion. The putrid material, however, may afford a favorable soil for the 
development and propagation of sepsis, so that the patient, when under 
observation, may be the victim of a mixed infection. Under prompt 
management sapremia generally terminates in recovery. Septicemia 
is exceedingly dangerous. Its manifestations are so varied that often 
when the patient survives she may be crippled for life, and under the 
necessity of sacrificing important organs. The progress of the disorder 
demands the most careful observation, with recourse to radical procedure 
whenever it is evident that local foci are influencing its continued prop- 
agation. Persistently high temperature, rapid, feeble pulse, a rapidly 
spreading peritonitis, a low muttering delirium, repeated chills, and the 



CERVIX AND BODY OF UTERUS. 35 1 

appearance of abscesses in different parts of the body are indications of 
the gravest import. 

Treatment. Prophylaxis is the most important consideration, in 
treatment, but is so closely associated with the work of the obstetrician 
that we will not consider it. A woman who develops symptoms leading 
one to suspect the occurrence of a septic process should at once be sub- 
jected to careful investigation. This careful scrutiny is advised in order 
to prevent the confounding of other conditions with sepsis. Finally, a 
pelvic exploration should be made, and all decomposing products, such 
as blood-clots, portions of placenta, or remnants of decidua should be 
removed. The patient should be placed across the bed; if the abdomen 
is tender, an anesthetic should be given, and two fingers wrapped with 
gauze introduced into the uterus, which, with the hand over the abdo- 
men, will permit the entire uterine cavity and wall to be explored thoroughly 
and all products and debris removed. The procedure not only re- 
moves the debris and contents of the uterus, but favors dislodgment of 
infected clots from blood-vessels and sinuses. The manipulation should 
be followed with an intra-uterine douche of sterile normal salt solution, 
or, better still, i per cent, saline solution composed of sodium carbonate 
gr. 2 1/2; sodium chlorid gr. 7 1/2; water 1000; formalin solution 1:1500- 
1000, or sublimate solution 1:3000. After irrigation the uterine cavity 
should be packed with iodoform gauze to be removed in twenty-four 
hours. If exploration of the uterus fails to disclose decomposing masses 
or other causes of sapremia the diagnosis of septicemia is justified. The 
conditions which point to the existence of pyemia have been indicated. 
In either septicemia or pyemia, intra-uterine manipulation will be unpro- 
ductive of any result unless instituted early. The micro-organisms soon 
penetrate beyond the reach of local measures. Curetment, by affording 
fresh avenues for infection, is harmful. The uterine cavity may be ir- 
rigated through a double current tube, once with a hot i per cent, saline 
solution, or solution of formalin or bichlorid, to ensure removal of blood- 
clots or other decomposing material. Sublimate douches are preferably 
followed with normal salt solution to avoid the danger of mercuric 
poisoning. 

The removal of decomposing products, irrigation of the uterus, and 
the internal administration of salines in sapremia, or putrid intoxication, 
usually establishes early convalescence. Not infrequently, however, 
there will be a marked rise of temperature after such a procedure, but 
it soon subsides. Sepsis, on the other hand, is caused by micro-organisms 
which have entered the blood, and kill, not so much by their presence, 
as by the toxins or poisons which they generate. Researches have seemed 
to demonstrate that these toxins or the killed micro-organisms injected 
into the circulation promptly generate an antitoxin which acts as an 
antidote to the original poison. My early experience in the treatment 
of sepsis by the administration of the antistreptococcic serum was such 
as to lead me to place great reliance upon its efficacy. Later this did 
not seem sustained. Recently, however, more careful methods of prep- 
aration render this treatment worthy of consideration. In severe cases, 



352 GYNECOLOGY. 

as much as ten cubic centimeters (two and a half drams) of the serum 
or lo to 200 millions of the dead micro-organisms should be injected in 
twenty-four hours. In less severe cases, smaller doses, three to six cubic 
centimeters of the former, or 2 to 8 millions of the bacteria can be used. 
The serum or vaccine should be administered daily until the abnormal 
symptoms subside. 

The advocates of serum-therapy and bacterial vaccines are doubtless 
correct in their demand that the material shall be recently prepared. 
Careful bacterial investigations of the secretions and blood of the infected 
patient are essential to accuracy in treatment as it is unreasonable to 
expect satisfactory results from the use of streptococcic serum or vaccines 
in staphylococcic infection. Unquestionably the use of autogenous vac- 
cines would seem the more scientific procedure, but it is not always 
practicable, for obvious reasons, as the condition of the patient will indi- 
cate in many cases the probability of streptococcic infection. In others, 
especially, where there is room for doubt, it is the wiser plan to use the 
stock mixed vaccines. Henry Schwarz, M. D., (St. Louis. Am. Jour. 
Obst., LXII, 1910, 895) asserts as the result of careful animal experi- 
mentation that: 

1. The use of bacterial vaccines must be based on bacterial diagnosis. 

2. The legitimate field for the use of vaccines will be found in the 
localized infections produced by the colon bacillus, the gonococcus, 
and the various staphylococcic infections. 

3. They were of no value in the strictly local streptococcic infection, 
and dangerous where partially localized. 

4. The bacterial vaccines are contraindicated in all acute infections. 
He seems to hope that more will be accomplished through the serums. 

It is important that the serum should be used early and in effective 
dose. Neither serum nor vaccine can be regarded as having sufficient 
specific value to justify reliance on its action alone, to the exclusion of 
other measures to sustain the patient and maintain her ability to fight 
the disease. The patient's strength should be maintained by a nutritious, 
easily digested diet, supporting remedies, and the judicious use of stimu- 
lants. The greatest care must be exercised by the physician to employ 
his means to combat the disease with intelligent consideration. The 
untimely use of supporting remedies and stimulants is often more damag- 
ing than valuable. To use them prematurely may decide the battle 
against the patient. In order to keep the digestive tract undisturbed 
for the most effective nutrition, remedial measures, as far as conditions 
will permit, should be administered per rectum or hypodermically. Qui- 
nin in suppository (gr. v-x) three or four times daily; strychnin, atropin, 
tincture of digitalis, digitalin or adrenalin chlorid solution (i : 1000) hypo- 
dermically should be given as indications demand. Action of the bowels 
secured by the proper use of salines facilitates the elimination of the in- 
fective products, though care should be taken to avoid undue depletion. 

Intravenous injections of normal salt solution has been of great service 
to the surgeon in overcoming shock and carrying patients over a critical 
period. This procedure is also serviceable in low septic conditions as 



CERVIX AND BODY OF UTERUS. 353 

it increases the volume of the blood, dilutes the toxic material, promotes 
secretion and the consequent elimination of poisonous products. Chlorid 
of sodium (2 1/2 parts) with bicarbonate of sodium (7 1/2 parts) making 
a one per cent, solution has proved especially efficacious in septic condi- 
tions as it increases the phagocytes and the consequent ability of the 
patient to resist the progress of the infection. 

The brilliant results achieved by Professor Baccelli, in 1889, in the 
treatment of pernicious malaria, by the intravenous injection of hydro- 
chlorid of quinin, directed the attention of the profession to the intravenous 
injection of germicides. Baccelli later instituted the intravenous injec- 
tion of corrosive sublimate in the treatment of syphilis, after the adminis- 
tration of mercury by other methods had failed. His experiments on 
the lower animals demonstrated the fact that albuminate of mercury, 
which was .first formed, was redissolved in an excess of albumin. 

The knowledge that micro-organisms enter the blood suggested the 
introduction of germicidal agents to render it an unfavorable soil for 
their multiplication. The difficulty has been to secure an agent to de- 
stroy the specific germ in the hemal circulation without inducing degenera- 
tive changes in the circulatory fluid. Carbolic acid, sublimate, and 
formalin have all been recommended as suitable agents for this purpose. 
In a case in which the conditions were such as to make it evident that 
death was imminent unless the poison could be arrested, I injected 1/8 
of a grain of sublimate in 500 centimeters of normal salt solution. The 
following day the patient developed an infarct which cut off the circu- 
lation in the end of the nose, and she died at the end of forty-eight hours. 
However, as air had entered, due to the faulty apparatus employed, it 
is not justifiable to condemn the bichlorid as the cause. Formalin was 
commended particularly by Barrows, of New York, and Maguire, of 
London. The latter, in his experiments, injected solutions as strong as 
1:500 into himself. This was followed by hematuria, albuminuria, 
cramp-like pains, and faintness. I have applied gauze, wet with formalin 
solution (1:1500-2000), to the peritoneum, with complete destruction 
of the endothelial covering of the involved surface, so that I should re- 
gard the injections of solutions of formalin, therefore, under i : 5000, as 
extremely dangerous, and as it has been claimed that it is germicidal in 
solutions of 1 : 200,000, a weaker solution still would seem preferable. 
As the simple injection of water into the blood-vessels causes degenerative 
changes in the blood-corpuscles, it would seem much wiser that these 
injections should be made in combination with normal salt solution. In 
cases, then, in which it is evident that the patient will succumb to the dis- 
ease unless it can be arrested, we should feel justified in proceeding to 
extreme measures with the hope of affording relief; and with our present 
knowledge of conditions, I should favor a mercuric solution in combina- 
tion with a normal salt solution as being the safest agent we can employ. 
It should not be given in greater strength than 1:5000. 

Localization of infection may result in abscess formation in the 
uterine wall, in the pelvic cellular tissue, in the tube, in the ovaries, or 
in pyemic abscesses in various portions of the body. The presence of 
23 



354 



GYNECOLOGY. 



such local collections indicate prompt surgical interference. Necessa- 
rily, the procedure must depend upon the site and extent of the lesion. 
If an exudate or inflammatory collection can be reached by a vaginal 
incision, through which the contents of the cavity can be evacuated, its 
sac enucleated and removed, or the cellular tissue opened up and drained, 
more serious destruction of tissue often can be avoided. Where the uterus 
remains large and extremely tender, or presents indications of localized 
peritonitis or localized abscess formation, and the condition of the patient 
will permit, the abdomen can be opened and hysterectomy performed. 
It should be capable of demonstration that the uterus is the seat of ir- 
reparable damage or a focus for the continued distribution of infection 




mMh'j'^ \.::i^. . "m 



"•f^ 



jj v^. 






Fig. 319. — Interstitial Endometritis. 
a. Free uterine surface, b, b, b. Hyperplasia of connective tissue, c, c, c, c. Obliteration of 
glands, d. Choking of gland from increase of fibrous tissue, e, e. Glands occluded and 
somewhat dilated. 



before it is removed. I have been consulted as to the advisability of 
hysterectomy where the patients have recovered without operation, and 
even given birth to children subsequently. In doubtful cases the uterus 
and pelvis can be explored by a posterior vaginal incision and the opportu- 
nity thus granted for peritoneal drainage will often afford the required 
relief. The excision of a section of an infected vein has been successfully 
performed, but one must be satisfied that the condition is not diffuse 
before resorting to such a procedure. 

When the temperature is elevated, the skin hot and dry, associated 
with tympanites and repeated vomiting, the most effective plan of treat- 
ment is to irrigate the stomach with hot normal salt solution, followed by 
intracolonic irrigation. The latter should be continued over several 
hours, or a quart of normal salt solution should be injected into the 



CERVIX AND BODY OF UTERUS. 355 

bowel every hour. The better plan is to elevate the foot of the bed and 
through a double rectal tube subject the rectum to more or less continuous 
irrigation with a one per cent, salt solution. The administration of large 
quantities of salt solution promotes elimination. The tongue and skin 
become moist, the secretion of urine increased, the pulse increases in 
volume, and the temperature becomes reduced. 

245. Chronic endometritis is an inflammation of the mucous mem- 
brane of the body of the uterus. It rarely, if ever, is the consequence 
of acute endometritis, but more frequently follows subacute processes 
and long-continued hyperemia. It is divided by Ruge into glandular, 
interstitial, and mixed varieties, according to the structure of the mucous 









h .J.- 



V-"^-' 
"'-{"'•y 







Fig. 320. — ^Hypertrophic Glandular Endometritis, shomn Increase in Size and Number 

of Glands. 
a, a. Glands dilated and containing secretion, h. Infiltration of leukocytes. 

membrane most extensively involved. In all the entire structure of the 
membrane is necessarily more or less affected. With thickening of the 
mucous membrane the glands become elongated, dilated, bent, and 
tortuous. Cells become swollen and proliferated, resembling those of 
the decidua. The vessels of the deeper portion of the mucosa are 
dilated and in a state of congestion. 

In peritonitis early drainage is desirable. It is accomplished readily 
by an incision above and parallel to each Poupart's ligament and through 
the posterior fornix of the vagina and the insertion of ropes of iodoform 
gauze between the openings. If the peritoneal involvement is extensive, 
a lumbar incision should be instituted. 

The operation should be done expeditiously and with as little disturb- 
ance as possible, trusting to nature to eliminate the material when a 
vent has been supplied. The Fowler-Murphy treatment with continu- 



356 



GYNECOLOGY. 



ous rectal instillation of salt solution should be employed. Compression 
on the tube should be regulated to permit the use of two quarts of solu- 
tion in twenty-four hours. 

The mucous membrane is frequently several times its normal thick- 
ness, soft, spongy, and easily scraped away. The surface presents veg- 










Fig. 321. — Hypertrophic Glandular Endometritis. Vertical Section through the Mucous 

Membrane. 
a. Blood-vessel distended with blood-cells, b. Gland penetrating muscular wall. 

etations or growths, which, according to De Sinety, are of three forms. In 
one, the tissue consists of dilated blood-vessels; in the second, of dilated, 
hypertrophied glands (Fig. 321); in the third, of embryonic tissue con- 
taining but few blood-vessels and only traces of glands. With these con- 
ditions are associated three kinds of discharge — sanguinolent, leukorrheal, 
and mucopurulent. As a result of the changes in the mucous membrane, 



CERVIX AND BODY OF UTERUS. 



OD/ 



not infrequently portions project as polypoid masses, which consist 
of either glandular or vascular structure. (Fig. 322.) In this condition 
the mucous membrane is thickened and granular in appearance, and the 
state has been called villous degeneration, or endometritis fungosa. With 
cell-proliferation in its connective tissue and the subsequent contraction 
of the gland its structure is compressed and obliterated, so that the surface 
is almost free from glands. Or, again, the orifices of the glands' ducts 
in places become occluded and cysts result. The hyperplasia of the 
uterine mucosa in some cases results in the desquamation of the epithelial 
layers at each menstrual period. This desquamation may take place in 
the formation of shreds or in a complete cast of the uterus, in which the 






»♦, , ^^s^/ ' r^' j?/i» »'>. 




Fig. 322. — Polypoid Masses Associated with Chronic Endometritis. 
a. Glands greatly dilated, ^^ith destruction of the intervening septum. 



orifices of the Fallopian tubes and the internal os are recognized. This 
condition is known as exfoliative endometritis, membranous dysmenorrhea, 
or, probably better, menstrual decidua. (Fig. ^2^.) 

Symptoms. The disease arises after abortion or labor, as a result 
of an attack of uterine inflammation, or an attack of gonorrhea. Oc- 
casionally, it may begin insidiously and without any assignable cause. 
It occurs usually in the multiparous, frequently in the later menstrual 
life. Nulliparae are not exempt. Even virgins are sometimes affected 
when the condition is known as virginal endometritis. This occurs 
especially in narrowing or stenosis of the external os. A form of the dis- 
ease occurs subsequent to the climacteric, known as senile endometritis. 
Endometritis is characterized by the following symptoms : leukorrhea and 
menorrhagia. The discharge from the body of the uterus is less viscid 
than that from the cervix. It may be clear, but more generally is 
mucopurulent; occasionally it is tinged with blood, so that the patient 



358 



GYNECOLOGY. 



imagines herself continuously unwell. The discharge flows freely or 
there is an apparent accumulation. Retention of the discharge and its 
evacuation in considerable quantity occur when endometritis is compli- 
cated by retrodisplacements or when the os is small. The discharge may 
have an offensive odor and be so irritating as to give rise to extensive 
excoriation of the vulva. Excessive menstrual flow, or menorrhagia, 
may or may not be present. Occasionally, it will be so profuse as to 
occasion a suspicion of malignant disease and cause a profound anemia. 
The resulting loss of vasomotor tonus results in increased tendency to 
hemorrhage. Dysmenorrhea, or painful menstruation, is not so common 
as' in disease of the appendages or in chronic metritis. It is especially 




Fig. 323. — ^Membranous Dysmenorrhea. 

marked when accompanied by the discharge of a menstrual decidua. 
The influence of endometritis upon conception is not fully determined, 
but che increased frequency with which women become pregnant subse- 
quent to a curetment renders evident that it has a restraining influence 
upon the occurrence of conception. Endometritis is a prolific cause of 
abortion. 

Diagnosis. The existence of leukorrhea or of irregular and profuse 
menstruation, associated with enlargement of the uterus for which no 
explanation external to the uterus can be found, justifies the suspicion of 
endometritis. The history of abortion, or prolonged convalescence sub- 
sequent to labor, confirms the suspicion. The use of the curet is of in- 
calculable advantage in determining the diagnosis. Portions removed 
with the curet will show small-cell infiltration of the entire glandular 
tissue, without glandular hyperplasia, or marked hyperplasia of glands 



CERVIX AND BODY OF UTERUS. 359 

with proliferation of the glandular epithelium. The epithelial cells be- 
come enlarged and granular, lose their cylindrical shape, and resemble the 
decidual cell. Endometritis, when uninterrupted, extends to the deeper 
structures, producing metritis. It predisposes to malignant change. 
When permitted to pursue an undisturbed course, it may involve the 
peri-uterine covering. Deposits occur in the cellular tissue about the 
ovary or around the orifice of the Fallopian tube, or the disease involves 
the pelvic peritoneum. Neglected cases result in cellulitis, salpingitis, 
ovaritis, peritonitis, the formation of abscesses, the destruction of tissue in 
the organs, and not infrequently, alas! in loss of life. Senile endometritis, 
is associated with retention of secretion which decomposes, producing an 
exceedingly offensive odor, and arouses the suspicion of malignant disease 
(Dunning). The examination of such a uterus reveals its walls thinned, 
the mucous membrane consisting of a thin layer of connective tissue 
covered with a single layer of flattened epithelial cells. 

Treatment. Constitutional treatment is of marked value, and will 
be discussed with chonic metritis. Prophylaxis will require rigid asepsis 
during labor or abortion, as well as in making gynecologic examina- 
tions. A rise of temperature or the suspicion of the retention of a 
portion of placental debris should be considered as indicating the neces- 
sity for thorough use of the curet, free irrigation, and in many cases gauze 
packing. Laceration of the cervix or of the pelvic floor should have early 
repair. All suspicious discharges must be removed by treating the cause. 
Before the third or fourth day an endometritis of gonorrheal origin is best 
treated by frequent irrigation with antiseptic solution, such as perman- 
ganate of potash (1:3000-2000), mercurol (i to 2 per cent.), protargol 
(o. 5 to I per cent.) . If the acute symptoms have subsided, paint -the cervix, 
and where the os is patulous, the cervdcal canal, with 50 per cent, solution 
of ichthyol in water, or glycerin, and later, if the condition persists, curet 
and pack with iodoform gauze. Careful antiseptic or aseptic curetting is 
the proper form of treatment in all forms of endometritis, whether com- 
plicated or uncomplicated. In serious cer\dcal lesions, with much eversion 
and thickening of the mucous membrane, curetting should be followed 
by Schroder's operation upon the cervix. Drainage is of incalculable ad- 
vantage in endometritis when complicated with slight catarrhal salpin- 
gitis. It will also prove serviceable in mild forms of peri-uterine inflamma- 
tion. Curetting is contraindicated in well-established pathologic changes 
in the adnexa and in chronic peri-uterine inflammation unless immediately 
followed during the anesthesia by an abdominal incision for the correction 
of the pelvic lesions. In addition to curetment, intra-uterine treatment 
consists in the employment of antiseptics and caustics. 

Free drainage should be considered as a prerequisite to all intra- 
uterine treatment. The inflamed uterine canal is similar to a sinus. Un- 
less the pent-up discharges have free vent, the irritation is aggravated. 
When the canal is patulous, large injections of a feeble antiseptic solu- 
tion such as formalin (1:2000), normal salt solution, or a 2 per cent, 
solution of bicarbonate of soda through a return-current catheter can be 
employed. The latter solutions, when used, are as salutary as the more 



360 . GYNECOLOGY. 

distinctly defined germicidal agents. If the cervical canal is insufficiently 
large, it should be dilated with laminaria tents, after which irrigation 
should be practised. In mild cases the canal may be swabbed, by means 
of a cotton- wrapped applicator, with tincture of iodin; in more severe 
cases, with carbolic acid. When the mucous membrane is thickened 
and tends to bleed or to furnish a profuse discharge, more active agents 
may be employed; silver nitrate, gr. xxx, to aq. destil., 5ss-j; zinc chlorid, 
3j-iv to fgj; chromium trioxid, gr. x-xxx, to fgj; fuming nitric acid, acid 
nitrate of mercury, tincture of chlorid of iron, pencils of silver nitrate, 
zinc chlorid, zinc sulphate, copper sulphate, or formalin. When strong 
caustics are used, precautions must be practised to protect the healthy 
vagina from contact with the solution. Indeed, in my judgment the em- 
ployment of the strong caustics is required very infrequently. More is 
to be gained where a strong effect is desired by the use of the curet and 
the subsequent applications of the milder agents, as argyrol (10 to 50 per 
cent.), protargol (5 to 10 per cent.), or the ordinary tincture of iodin. A 
mass of absorbent cotton should be placed beneath the cervix prior to 
the application, and the superfluous caustic should be removed by spong- 
ing before the pledget is withdrawn. Pencils are objectionable in that 
they produce sloughing of the cervical mucous membrane and cause the 
development of atresia. 

Dilatation and the curet are generally recommended for membranous 
endometritis but have little influence in affording relief. Otto Maier 
recommends cotarnin phthalat gr. 3/4 in capsule every three hours, 
beginning three days before the flow and continuing through it. When 
other methods fail, Toland advocates the application of Bier's suction 
glasses for fifteen to thirty minutes daily, a few days before and during 
the flow. 

Tampons. Intra-uterine treatment should be supplemented by placing 
beneath the cervix a tampon, preferably saturated with a preparation of 
glycerin, a 50 per cent, solution of boro-glycerid in glycerin, a 10 to 15 
per cent, solution of ichthyol in glycerin, or a 25 per cent, ointment of 
ichthyol in lanolin. The following prescription is an excellent astringent 
and antiseptic: 

I^. Pulv. alum., f 5j 

Acid, carbolic, o vj 

Glycerin., Oj. 

Various ointments, either astringent or alterative, with lanolin as a 
base, may be used upon the tampon. A tampon improves the circulation 
by raising and maintaining the uterus at a higher level. The antiseptic 
tampon may be retained from twenty-four to seventy-two hours, according 
to its character. When the tampon is not used, or after its removal, a 
vaginal douche of two or three quarts of hot salt water (110° to 120° F.) 
should be used twice daily, with the patient in the recumbent position. 
When using very hot injections cover the vulva and perineum with vaselin, 
to prevent burning. The employment of rock-salt, an ounce to the quart, 
in a douche, promotes its efficiency. Scarification under continuous 



cerm:x and body or uterus. s6i 



irrigation will often prove of advantage, and is more effective than leeches. 
An iodoform gauze tampon should follow. Intra-uterine injections have 
been employed for endometritis, but should never be used unless the canal 
is sufficiently patulous to permit the escape of the superfluous fluid. 
The better plan is to employ a pipet or syringe by which one, two, or three 
drops may be introduced. Occasionally, even this small quantity will 
cause violent uterine colic. These attacks are not necessarily dangerous, 
but they are not calculated to encourage the continuation of treatment. 

The treatment par excellence in chronic endometritis is the use of the 
curet. In senile endometritis the important consideration is drainage; 
to insure this, sometimes it may be necessary to employ a tube. The 
cavity should be irrigated frequently w4th an antiseptic solution. 

246. Chronic metritis is an inflammation in the muscle-wall of 
the uterus, leading, when long continued, to increased connective-tissue 
formation. The term metritis is used in a comprehensive sense, and 
comprises conditions which have been described by different ^\Titers under 
such terms as chronic parenchymatous inflammation (Scanzoni); sub- 
involution fSimpson) ; diffuse proliferation of connective tissue (Klob) ; 
infarction (Kiwisch) ; hyperplasia of fibromuscular tissue, similar to fibroid 
tumors (\'irchow) ; diffuse interstitial metritis (Xoeggerath) ; irritable 
uterus (Gooch) . The term may be criticized from a pathologic standpoint, 
as there is no chronic inflammation of the muscle-fiber of the uterus, but 
an increased amount of connective tissue, out of proportion to that of the 
muscle-fiber. Clinically the term is satisfactory, as it enables us to com- 
prise a variety of conditions which may be developed from different causes 
but produce a similar group of symptoms. It has been objected that, by 
inference, there has been a profuse acute inflammation, which is not the 
case, as chronic inflammation of the uterus does not follow the acute. 
It is more correctly described as an increased tissue formation, dependent 
on long-continued congestion. The term chronic is applied to analogous 
forms of inflammation in other organs and structures of the body, as 
cirrhosis of the liver, which describes a condition similar to that which 
is found in the uterus. Subinvolution is, in some English books, described 
separately, though it is due to the same cause. 

The differential diagnosis between subinvolution and chronic metritis 
is impossible, and the treatment of the two conditions does not differ. 
The altered condition of the uterus wfll vary with the period at which the 
patient comes under observation. In the early stages the organ is en- 
larged, hyperemic, and soft. Later, it may decrease in size, though it is 
stfll large, and then becomes hard, indurated, and anemic. The enlarge- 
ment of the organ is uniform, so the shape is not altered. Upon opening 
the abdomen of such a patient the peritoneal surface will present a normal 
color, or patches of extravasated blood may be present. On section, in 
the early stages the tissues will be soft, hyperemic, easily incised; later, 
firm, cartilaginous, presenting a whitish color, the walls thickened, and 
the cavity of the uterus enlarged. Xot infrequently the organ will be 
found as firm and dense as a mature fibroid growth. During the first 
period, De Sinety says, the dominant lesion is the presence of a large 



362 GYNECOLOGY. 

number of embryonic elements throughout the thickness of the muscular 
wall. These are more particularly situated around the blood-vessels, 
or they may form islands more or less separated from one another. The 
second period is characterized by two changes: marked dilatation of the 
lymphatic spaces; and localized hyperplasia around the blood-vessels. 
We may find it difficult to determine whether the muscular tissue remains 
normal, or is present in decreased quantity. Fritsch examined uteri 
removed for cancer, and found associated evidences of chronic metritis, 
in which the following pathologic changes were noticed : The arrangement 
of the muscular fiber and connective tissue is less regular than in the 
normal, and the latter is greatly increased in quantity. Blood-vessels are 
more numerous and tortuous. The vessel lumen is contracted, its tunica 
media is thickened, and the contour of the vessel is masked by the de- 
generation of the connective tissue in its wall. The lymphatic spaces, 
instead of being narrow clefts, are gaping; the peritoneum is thickened. 
Both Corneuil and Snow-Beck described an increased number of round 
and oval globules with amorphous tissue in the uterine walls. The in- 
crease in the size of the organ is due to the presence of this rather than to 
the increase of muscle-fiber. 

Etiology. — The causes of chronic metritis are predisposing and excit- 
ing. The former may be divided into : {a) Those which operate by inter- 
ference with the normal involution of the puerperal uterus; (h) those 
which are due to the production of repeated or protracted congestion. The 
first class comprises : (i) retentions within the uterus of portions of placenta, 
membranes, or blood-clots; (2) cervical lacerations; (3) pelvic inflamma- 
tions subsequent to labor; (4) too short convalescence following delivery; 
(5) nonlactation; (6) repeated miscarriages. Two factors are essential to 
the accomplishment of involution : first, fatty degeneration of the muscle- 
fiber; second, removal of the products of degeneration. Now, subinvolu- 
tion or failure of the uterus to undergo complete involution is due not to 
want of degeneration of muscle-fiber, but to substitution of connective tis- 
sue for the products of this degeneration. Metritis, then, is generally found 
in women who have borne children, and it has been asserted that invo- 
lution is retarded by the removal of the ovaries, although a patient of 
mine who completed her gestation after the removal of both ovaries did 
not manifest any failure in the process of involution. Any irritation in 
or about the uterus will cause a chronic metritis. This explains the effect 
of retention of portions of the placenta or membranes, of lacerations of 
the cervix, and of the existence of peritonitis or cellulitis, as these condi- 
tions interfere with the circulation, which is also affected by premature 
getting up following labor. The organ is heavy, and the increased weight 
leads to its being displaced to a lower level, producing passive congestion. 
Passive congestion is decreased by any cause which increases uterine con- 
tractions; the physiologic stimulus of nursing excites contraction reflexly 
through the mammae and favors involution. Abortions especially are in- 
strumental, for the reason that the patients do not take as much care of 
themselves as they would subsequent to a labor, and the stimulus of lacta- 
tion is absent. After an abortion conception is likely to occur before the 



CERVIX AND BODY OF UTERUS. 363 

process of involution is complete, and this favors the recurrence of 
abortion. 

The second class of cases, which operate through production of re- 
peated or protracted congestion, includes displacements of the uterus, 
the presence of tumors in or near it, and any condition which produces 
increased flow of blood to the uterus, such as endometritis and the free 
use of caustics. To this class also belong malformation, incomplete 
development, congenital anteflexion, conic cervix, stenosis of os, improper 
clothing, exposure to cold, and masturbation. Metritis is favored at each 
menstrual period, by exposure to cold, especially when the uterus is 
displaced or the cervix is contracted or lacerated, by excessive copulation 
or its practice during menstruation, and by gonorrheal infection from an 
incompletely cured husband. 

Chronic contusions from the use of a pessary may engender the in- 
flammation. The intra-uterine stem-pessary is capable of doing the most 
injury. 

Symptoms. In the large majority of cases the patient wdll date her 
trouble from a confinement. Not infrequently she will report repeated 
abortions, and that she subsequently regained her health very slowly. 

The symptoms are not characteristic, but are similar to those found in 
cancer, fibroma, displacements, and other local disorders. They are: 
weakness; pain or aching over the lower lumbar and sacral regions; a 
sensation of weight and bearing down, as if the pelvic organs were about 
to be extruded; an apparent loss of power in the lower extremities; points 
of anesthesia over the anterior surface of one or both thighs; painful con- 
tractions of the uterus; irritable bladder; constipation; loss of all pleas- 
urable sensation during the sexual relation; pricking pain in the eyes and 
weak sight; photophobia; occipital pain, but more frequently pain over 
the coronal suture; and disturbances of menstruation, as dysmenorrhea, 
abnormal bleeding, menorrhagia, or metrorrhagia. In weak patients are 
found amenorrhea, leukorrhea, hydrorrhea, hydrorrhea gravidarum, 
puerperal hydrorrhea associated with retention of portions of placenta 
and clots. Not infrequently there are loss of appetite, nausea, dyspepsia, 
and enfeebled assimilation. The patient is pale, anemic, and exceedingly 
weak, with dark circles beneath her eyes. She sufl'ers from palpitation 
and a sense of oppression, is exceedingly despondent and profoundly 
melancholic. Acute mania, epilepsy, hysteria, and neurasthenia are 
occasionally induced, and are always aggravated by the existence of chronic 
metritis. The diseased condition under discussion is responsible for the 
majority of cases of semi-invalidism. The patient is continuously con- 
scious that she has a uterus; the distress is increased by exercise and 
lessened by rest. The constipation and digestive disturbance are aggra- 
vated and increased by dread of pain and by her sedentary habits. The 
patient can suffer from acute exacerbations, with diarrhea and rectal 
tenesmus, as a result of extension of the inflammation to the rectum. 

Menstrual disturbances are common, and largely induced by the 
accompanying endometritis, which is called hemorrhagic endometritis, 
from the bleeding. 



364 GYNECOLOGY. 

The hemorrhage probably is due quite as often to the diminished con- 
tractile power of the organ as to the substitution of connective tissue for 
the muscle-fiber. The associated disease of the mucous membrane adds 
to the dysmenorrhea. This may precede, be simultaneous with, or 
follow the period, but is generally continuous with it, in the form of in- 
creased backache, pressure, and pelvic discomfort. 

Leukorrhea is produced by alterations of the uterine mucous mem- 
brane. Frequently in the aged a hydrorrhea develops, with a periodic 
discharge so offensive as to lead to the suspicion of the development of 
malignant disease. 

Sterility is a natural consequence of the prolonged existence of chronic 
inflammation, not only from alterations in the structure of the wall and 
mucosa, but probably much more from the superadded changes in the 
pelvic peritoneum, affecting the tube and ovaries. The escape of the 
ovum may be prevented by extensive adhesions fixing the ovary, or through 
thickening of the ovarian tunica albuginea, which prevents its exit from 
the maturing Graafian follicle. The Fallopian tube may furnish the 
obstacle, through closure of its abdominal or uterine end, or by stricture 
along its course. 

In the earlier stages of the inflammation the susceptibility to pregnancy 
may be engendered by alterations in the mucosa which unfit it for the 
complete nutrition of the developing embryo, and abortion or premature 
discharge of the contents follows. The substitution of connective for 
muscular tissue, by the consequent uterine inertia, at the completion of 
gestation, renders delivery tedious and increases the danger of post- 
partum bleeding. 

Chronic metritis is responsible for many of the sofa and bath-chair 
population — the nervous, debilitated, dyspeptic women who wander from 
physician to physician or crowd the watering-places during the summer. 
The condition is frequently unrecognized and untreated, and the patient 
is condemned to suffer deeper and deeper wretchedness. 

Physical Signs and Diagnosis. The uterus is uniformly large. Its 
walls are firm and rigid — in later stages almost as resistant as a fibroid 
tumor. 

The organ may be in a normal position, situated at a lower level, or 
displaced. It may be freely movable; more or less fixed; readily out- 
lined or fixed in a mass of pelvic exudate. The organ is sensitive to 
pressure. 

Differential Diagnosis. Pregnancy in the early stages presents a 
history of cessation of menstruation and of increased discharge. The 
uterus is enlarged, the cervix soft, while the body bulges like a jug and is 
not resistant. Cancer usually involves the cervix, though the body may be 
the site of its origin. When the latter is involved the bimanual examina- 
tion will disclose points of increased resistance. Bleeding results from 
severe manipulation, and an offensive, thin, and serous discharge will 
probably be present. Pain is a frequent symptom, and occurs most 
severely toward evening. The use of the curet or digital exploration 
after dilatation with tents may be required to establish the diagnosis. 



CERVIX AND BODY OF UTERUS. 365 

The curetted tissue in cancer is friable from infiltration, exhibiting under 
the microscope the characteristic cellular structure. 

Small fibroids are frequently difficult to recognize, especially when in- 
terstitial or submucous. The irregular enlargement, well-defined points 
of resistance, and frequently intermittent pain are diagnostic. Digital 
exploration of the uterine cavity determines the presence, size, and situa- 
tion of the growth. Salpingitis is often associated with metritis, when it 
may be difficult to determine which predominates. A small ovarian 
tumor may cause uterine hemorrhage. 

Rectal disease often produces symptoms simulating chronic metritis. 
The general health may be so affected as to cause the local manifestations 
to be overlooked. Thus, the patient may complain of persistent cough, 
difficult breathing, or progressive emaciation, or the stomach may be the 
source of trouble, causing loss of appetite, flatulence, and gurgling, and 
presenting other evidences of dilatation. She may have precordial anxiety, 
palpitation, or cardiac and vascular murmurs. 

It is a good rule to make a careful uterine examination in all cases of 
chronic disease. 

Course and Prognosis. Metritis in all forms is obstinate and rebellious. 
The mucous membrane, muscular wall, and serous covering in turn are 
affected, followed by uterine sclerosis, cyst formation, and, finally, chronic 
metritis. In alterations of structure we cannot hope to cure in the 
sense of restoration of altered tissues; we can hope only for arrest of the 
process, relief of congestion, and amelioration of unpleasant symptoms. 

Treatment. The best treatment is preventive. It consists in thoroughly 
emptying the cavity of the uterus after labor; in early repair of lacera- 
tions; in the relief of inflammatory conditions existing about the uterus; in 
stimulating involution of the organ by hot vaginal douches; in the ad- 
ministration of ergot and remedies that will facilitate the contraction of its 
muscle-fibers; in the exercise of such measures as will diminish congestion; 
in preventing the patient from rising too early from bed after pregnancy 
or abortion, and, when the condition exists subsequently, obliging her 
to remain in bed several hours daily, and to avoid sedentary occupations 
and long standing. Whfle it is important that the patient should have 
sufficient rest, it is equally desirable that this should not be excessive. 
A certain amount of exercise in the open air is as desirable as rest. Tight 
clothing should be excluded. If the abdominal muscles, however, are 
very much relaxed, a snugly fitting abdominal binder affords great com- 
fort and relief. This relaxation of the abdominal muscles is not infre- 
quently associated with relaxation of the vaginal walls, when the use of a 
ring-pessary gives comfort. The circulation of the pelvis should be stimu- 
lated by vaginal douches of either hot or cold water. The latter are more 
stimulating, but few patients can employ them. Patients should take a 
hot douche containing rock-salt, at a temperature of 103° F. to 120° F., 
for ten or fifteen minutes before retiring. These douches are more 
effective when the patient is in the recumbent position. She can lie 
across the bed with her pelvis upon a basin or rubber pad, which should 
drain into a pail below, while her feet rest upon chairs. A douche bag, 



366 GYNECOLOGY. 

containing at least three pints, should be placed three feet above the level 
of the patient. Prior to its use the vulva and perineum should be coated 
with vaselin, to protect from the heat. The tube should be introduced to 
the cervix, and from three to ten pints of fluid should be used with each 
douche. Occasionally, warm baths should be used simultaneously with 
the vaginal douche. A cold hip-bath in the morning will be of great 
service. Medicated baths and waters are often of value. A course in 
hydrotherapy will frequently be serviceable. In catarrh or for scrofulous 
and chlorotic patients iron waters are beneficial. In nervous patients 
the character of the water is unimportant, but the patient should be en- 
couraged to take large quantities. With dyspeptics, alkaline waters are 
desirable. In the lymphatic and scrofulous cases waters impregnated 
with chlorid of sodium are very efficient. These are also of value in some 
forms of chronic metritis where engorgement of the uterine body pre- 
dominates. Patients not infrequently derive great advantage from change 
of air or scene, new surroundings, new relations, or a visit to the seashore 
or country. Constipation should be combated, preferably with foods, 
such as vegetables, Graham bread, prunes, nuts, and raisins; often effec- 
tively with other agents, as a teaspoonful of white unground mustard in 
water at meals; enemas to which glycerin is added; the administration of 
mineral waters — Friedrichshall water, Carlsbad salts, or Hunyadi Janos. 
The Carlsbad salts are of particular value to bilious patients. A tea- 
spoonful should be dissolved in a glass of water and drunk in repeated sips 
during the morning. Friedrichshall and Hunyadi act best when mixed 
with equal quantities of hot water. A good mixture is a tablespoonful of 
the following preparation: 

I^. Magnesii sulph., 5 vj 

Quinin. sulph., gr. xxiv 

Acid, sulphuric, dilut., 

Tinct. capsici, aa f 3 j 

Aqua, ad f 5 vj M. 

SiG. — Tablespoonful three times daily. 

Contraction of the uterine muscles may be increased by the ad- 
ministration of ergot, which should be given in doses of gtt. xx to f 5j of 
the fluidextract t. d. When the condition is complicated with menorrhagia, 
extract of hydrastis canadensis may be combined. An effective prescrip- 
tion would be a mixture of ergot and hamamelis. (Section 95.) Potash 
salts are especially beneficial in chronic inflammation of the uterus. 
Chlorate of potash is highly recommended by Tait. lodid of potash, 
however, is equally effective, and, when the patient is nervous and restless, 
may be combined with a bromid, giving of the iodid, gr. v, with bromid, 
gr. X, largely dfluted with water, three times daily. Potash salts may be 
administered in the bitter tonics, a? in compound tincture of cinchona or 
compound tincture of gentian. In the anemic and debilitated, iron, strych- 
nin, quinin, arsenic, cod-liver oil, and malt extracts are beneficial. The 
general health should be carefully watched and any deranged condition 
of the various organs should be corrected. During the menstrual period 
patients should be confined to the sofa. When pelvic distress is marked, 



CERVIX AND BODY OF UTERUS. 



367 



or metritis complicated by inflammation in the surrounding structures, 
benefit will be derived from painting with counterirritants, in the form of 
small blisters over the inguinal region, or the use of iodin or of croton oil. 
A good mixture is croton oil, one part; tincture of iodin, two parts; sulphuric 
ether, five parts. This can be painted over the hypogastric and iliac 
regions until a crop of pustules arises. Then the application should be 
discontinued until the pustules have healed. Exercise care not to allow 
the application to be made in the groin. Blistering fluid may be applied 
to the cervix and to the vault of the vagina, or tincture of iodin, or a 
combination of tincture of iodin and glycerin, may be thus used. Scanzoni 
advocated this application : 

1^. Potass, iodid., gr. iv 

Glycerin., ttlxxx. 

When metritis is complicated by cervical catarrh, puncturing or scari- 
fying the cervix, under an antiseptic stream, will be beneficial. Consider- 
able depletion can thus be effected and the patient relieved. After the 




Fig. 324. — Uterus Dilated with Graduated Bougies. 



bleeding has stopped, a tampon of cotton and gauze, saturated with one of 
the preparations of glycerin, will prolong the depletion. A tampon raises 
the uterus to a higher level and improves its circulation, while, medicated 
with glycerin, it has a depletive or cholagogue effect upon the vessels of the 
cervix, causing a profuse watery discharge. The patient may be instructed 
how to introduce these tampons, and allowed to use them daily. A tampon 
saturated with a 50 per cent, solution of boroglycerid in glycerin, a 10 to 20 
per cent, solution of ichthyol in glycerin, or carbolic acid (1:16) may be kept 
in place for one to two days. A tampon anointed with one part of ichthyol 
to four of lanolin is valuable when more or less irritation of the vagina is 
associated with the uterine lesion. In laceration of the cervix, where it 
has subsequently become hypertrophied, Emmet's operation is of service 



368 



GYNECOLOGY. 



in relieving the congestion and promoting involution of the organ. If 
the cervical mucous membrane is much everted, with papillary projections 
and eroded surfaces, amputation of the cervix by the single-flap method 
advocated by Schroder (Section 208) will be more effective. Any dis- 
turbances of menstruation, such as dysmenorrhea and menorrhagia, 
should receive treatment suitable for endometritis. (Section 243.) For 
this condition, as well as for the chronic metritis, dilatation and curettage of 
the uterus are of value. The dilatation is preferably done with Pratt's 
dilators, as these instruments gradually stretch the uterine canal without 
danger of tearing, unless the dilatation is excessive, which may occur in the 
use of the parallel-bar dilators. 




Fig. 325. — Uterine Cavity Packed with Gauze after Dilatation. 



After preparation of the patient (Section 131) she is placed upon her 
back, the uterus is exposed by the Edebohls speculum, the cervix is seized 
and fixed with a double tenaculum, preferably with two, when there will be 
no tearing out under the strain of dilatation, and the bougies are intro- 
duced, thus gradually dilating the cervical canal. The dilatation is followed 
by the use of the curet. This instrument may be blunt or sharp; the 
latter is preferable, if carefully used. The handle of the instrument, 
should be perforated, so that the surfaces can be irrigated as the curetting 
is done. The instrument is held lightly between the thumb and finger, 
is passed into the uterus and drawn down on all sides of the organ in long 
sweeps, paying particular attention to the angles of the body and to the 
orifices of the Fallopian tubes. The use of the curet in this manner does 
not remove the entire mucous membrane. Should it do so, the mucous 



CERVIX AND BODY OF UTERUS. 369 

membrane would be regenerated from the portion of the glandular 
structure which penetrates the muscular wall. The curettage may be 
followed by swabbing out the uterine cavity with tincture of iodin, a 
combination of tincture of iodin and carbolic acid, perchlorid of iron, or 
preferably a saturated solution of iodoform in ether. When any of these 
agents, except the last, are used, the uterus should be irrigated again, 
thus removing any clots and superfluous medicine. If bleeding is slight, 
the uterine cavity need not be packed. When considerable discharge 
exists, iodoform gauze packing should be used. Gauze packing is service- 
able first in that it acts as a tampon, decreasing the danger of bleeding or 
of the formation of a blood-clot, which could become infected and cause 
extension of inflammation to surrounding structures. Second, by its 
pressure upon the surface it favors exudation and bars the entrance of 
septic material to the uterine sinuses; third, by its capillary action it affords 
a limited amount of drainage; fourth, by its presence as a foreign body it 
stimulates uterine contraction and promotes the process of involution. 
The vagina is cleansed carefully and a gauze pad is placed within it to sup- 
port the uterus. This gauze dressing may be permitted to remain two or 
three days. When it is removed the vagina should be irrigated once or 
twice daily with a bichlorid formalin or, better, chlorid of sodium solution. 
When the uterine cavity has been the seat of extensive inflammation, with 
a predisposition to hemorrhage, the removal of the gauze may be followed 
by uterine irrigation through a double-current catheter. In hydrorrhea 
or pyometra in the aged it is very important to make sure that drainage is 
established. The accumulation of fluid within the uterine cavity makes 
the uterus a sac whose contents become infected and produce an occasional 
profuse discharge, causing the patient great alarm. Drainage should be 
insured, when necessary, by the introduction of a drainage-tube, through 
which the cavity is well irrigated and cleansed. Remedies should be 
applied to the uterine cavity to establish a healthy inflammation and arrest 
the abnormal accumulation. If hydrometra or pyometra w^hich a pes- 
sary fails to correct is associated with a displacement of the uterus, the 
advisability of hysterectomy should be considered, particularly when the 
woman has passed the climacteric. Uterine adhesions or peri-uterine 
inflammation need not contraindicate curettage necessarily, as frequently 
the increased drainage thus secured will result in the relief of the peri- 
uterine disease. In patients who have been for a great length of time 
exceedingly nervous, hysteric, with general health destroyed, suffering 
from delusions or illusions, exceedingly irritable temper, a source of 
worry and distress to the family and to themselves, no better plan of treat- 
ment can be instituted than that advocated by Weir Mitchell for neuras- 
thenic patients. This treatment consists in placing the patient in bed; at 
first upon a distinct milk diet, with careful regulation of the bowels, correc- 
tion of any disordered condition of the alimentary canal; and, later, forced 
feeding, with as large a quantity of food as the patient can properly digest. 
She is under the control of a discreet, careful nurse, who allows her to 
take no exercise — nor even to move without assistance. In place of 
exercise she is given, once daily, thorough massage, thus carrying forward 
24 



370 



GYNECOLOGY. 



the blood-current, stimulating the absorption of waste material, and caus- 
ing the introduction into the uttermost parts of the body of blood containing 
oxygen. The anemia which characterizes such patients is thus rapidly 
overcome, the number of red blood-corpuscles greatly increases, while the 
elimination of waste material is promoted. Once daily she is given an 
application of the faradic current — ^general faradization. She is isolated 
from the members of her family, and during this period of isolation is 
brought under careful mental discipline, which aims to stimulate her 
ambition, to overcome her subjection to the abnormal condition. At the 
end of six weeks or two months the patient undergoes a complete physical 
and mental change. 

247. Inflammation of the Fallopian tube is a frequent result of 
infection, and the gravity of the physical changes is directly in proportion 




Fig. 326. — Acute Salpingitis. 
a. Swollen and edematous fold. h. Inflammatory exudate, c. Dilated blood-vessel, d. 
Desquamation of epithelium, e. Infiltration of leukocytes. /. Disintegration of longi- 
tudinal fold. 

to the virulence of the poison. Gonorrhea and sepsis are the most fre- 
quent forms of infection which invade these organs. The invasion may 
occur through the uterus by the continuous mucous membrane, or through 
the blood-vessels or lymphatics, the former being the more frequent. 
Inflammation may involve the mucous membrane, the muscular wall, and 
even the peritoneum. It may be catarrhal or suppurative. Gonorrheal 
infection most frequently reaches the tube by the mucous membrane of the 
uterine body, and is more prone to involve the tubal mucosa, resulting 
in either catarrhal or suppurative salpingitis. It may, however, pass 
rapidly over the surface epithelium into the deeper structures of the tube, 
and causes profound destruction. Infection in rare instances enters 



CERVIX AND BODY OF UTERUS. 



371 



through other avenues such as an inflamed or diseased appendix, es- 
pecially upon the right side, through adhesions to a knuckle of intestine, 




Fig. 327. — Chronic Salpingitis showing Agglutination of Folds. 
a. Union of folds forming gland-like areas, h. Thickened and retracted fold. c. Desqua- 
mation of epithelium, d. Hyperplasia of tubal wall. 




Fig. 328. — Extensive Pus-collections ^Yith General Adhesions. 

particularly if the tube contains a collection of blood, and, finally, through 
the peritoneum, in which case, however, the infection is generally tubercu- 
lar. The entrance of infection into the tube is followed sooner or later by 



372 



GYNECOLOGY. 



evidences of inflammation. The epithelium becomes swollen, edematous, 
and granular, with the infiltration of inflammatory materials into the deeper 
layers. Serous effusion takes place into the tubal canal. (Fig. 326.) Loss 
of the cilia from the epithelium also occurs, especially upon the free surface, 
while they may be retained upon that portion lying between the folds. 
The epithelium will be found well preserved upon the surface of the tubal 
mucouL membrane even when suppurative processes exist. (Fig. 327.) 
The iiritating discharge from the tube leads early to irritation of the peri- 
toneum and agglutination at the 
abdominal end of the tube, while 
the swollen structures obstruct 
the uterine orifice. The exudate 
which collects in the tube may 
be serous or purulent, according 
to the virulency of the infection 
and the resistive force of the 
patient. In either case the exu- 
dation is likely to increase, form- 
ing a clear serous collection in 
the one case which is known as 
hydrosalpinx or sactosalpinx, 
while the virulent process (Fig. 
328), which results in a more or 
less extensive pus-collection, is 
called a pyosalpinx. (Fig. 329.) 
Occasionally the excessive hyper- 
emia or a partial twisting of the 
base may cause rupture of the 
blood-vessels with an intratubu- 
lar accumulation of blood. This 
condition is denominated hema- 
tosalpinx. It is, however, more 
frequently associated with the 
retrogressive processes of ectopic 
gestation. As a result of the 
inflammatory process the tube 
may assume the form of a simple 
sac, which gradually becomes distended until it attains a large size, and 
becomes a thin-walled cystic tumor. If the peritoneal wall has not been 
involved, the tumor may remain freely movable, whether it contain serum 
or pus. Such a sac may, occasionally, become twisted upon itself until 
the venous circulation is partially or completely obstructed, and then 
rapid increase in size results from the hemorrhage, which takes place not 
only into the sac, but also, occasionally, into the peritoneal cavity. 

I saw in consultation a young girl who had an acute attack of pelvic 
inflammation. Examination revealed a large mass on each side. That on 
the left was situated above the uterus, and the one on the right posterior 
to and below the fundus. I performed an operation. So much blood 




Fig. 329. — Pyosalpinx. 



CERVIX AND BODY OF UTERUS. 



was found in the abdomen that ectopic gestation was suspected. The 
hemorrhage in this patient came from the left tubal mass, the neck of 
which was twisted near the uterus. The tubal sac was dark (Fig. 332), 
and covered with clotted blood, which also filled that side of the pelvis. 

The right sac was 
clear and free from 
blood. Both sacs 
were found to contain 
pus, the left being 
mixed with blood. 
Both tubes were free 
from adhesions. 
Sometimes the dis- 
tention of the tubal 
sac overcomes the 
swelling of the mu- 
cous membrane of the 
uterine end, and, 
therefore, its opening 
remains patulous and 
permits its contents 
to escape, after which 







9&m 



r^'-^^i*'" 

















■^ 






"^m^^^^^ 
^^^-^^m 










:^^^-^>' 

^^P^^:^' 






:SSi 




^^>^^^ ..^^-^^^ 

m^B^ 



<'? 






^^^s,.: 











t*J 






Mm^ 



Fig. 330. — Section from Wall of Pus-tube. 
a, a, a. Folds matted together forming gland-like spaces. 
b, h. Folds undergoing dissolution, c. Shows complete 
desquamation of epithelium covering folds, d, d. 
Blood-vessels distended with blood-cells, e. Leuko- 
cytic infiltration. 



Fig. 331. — Single Fold from 
Wall of Pus-tube, en- 
larged. Line through 
upper portion shows area 
of extensive hyperemia. 



the sac attains a favorable position. Such a condition may lead to occa- 
sional discharges of a considerable quantity, of fluid through the uterus, 
giving rise to the phenomenon known as hydrops tubse profluens, or inter- 
mittent hydrosalpinx. Inflammation of the tube involving its muscular 



374 



GYNECOLOGY. 



wall causes a shortening of its longitudinal muscular fibers, which, owing 
to the mobility of the subserosa, permits the fimbria to be drawn into the 
tube and the peritoneum to be pushed over it like the prepuce over the 
glans penis in phimosis. (Fig. ^t,^.) The peritoneal edges coming in 
contact are agglutinated, and the tube is sealed up. If the fimbriae are not 
completely withdrawn, the protruding fimbriae may serve as an avenue for 
leakage in subsequent distention of the sac and thus cause recurring 
attacks of localized peritonitis. (Fig. 334.) 




Fig. 332. — Distended Pus-tubes Removed from Young Girl. 
A. Tube whose pedicle was twisted. Sac filled with blood and pus. B. Right tube filled with 

pus. 



I'he tubal inflammation, instead of forming the cystic tumor already 
described, may result in extensive small-cell infiltration and thickening of 
the longitudinal folds, which necessarily decreases the caliber of the tube. 
Furthermore, in places the edges of the folds lose their epithelium, become 
more or less adherent, and upon microscopic section present the appear- 
ance of distended glands. Such a condition has been called salpingitis 
cysto-adenosa, but this term, like salpingitis follicularis, pachysalpingitis, 
and other designations, is an unnecessary distinction. The inflammatory 
infiltration frequently involves the folds and wall of the tube, producing 



CERVIX AND BODY OF UTERUS. 



375 



such hyperplasia of these structures as almost to obliterate the tubal canal 
and to form a large sclerosed mass. The contraction of the circular 
fibers may cause the formation of a series of small sacs, each of which is 
independent of the others. The only relief is afforded by extirpating the 




Fig. 333. — Convoluted Fallopian Tube from Perisalpingitis. 

tube. In the virulent infection the peritoneal envelope of the tube becomes 
involved by extension from its abdominal end or through its walls, and 
extensive adhesions unite it to coils of the intestine, the uterus, the ovary, 
or the pelvic peritoneum. The enlarged and swollen tube drops down into 
the retro-uterine cul-de-sac, and generally becomes adherent to the 



/ 




Fig. 334. — Incomplete Inflammatory Closure of the Fallopian Tube. 

Fimbriae Unretracted. 



Portions of 



sigmoid flexure or side of the rectum. As the sac becomes more and 
more distended the union thus formed may permit the'establishment of a 
communication with the lumen of the bowel, through which the tubal 
abscess drains. The tube of one side, dropping into the pelvis, may 
become adherent to the extremity of the other and form a common pus 



37^ 



GYNECOLOGY. 



cavity, which may attain a large size. (Fig. ;^^i,.) Infection of Douglas' 
pouch may follow rupture of the tube, causing a walled-off abscess which 
fills the entire pelvis. The intimate association of the abdominal orifice 
of the tube with the ovary causes frequent adhesions between these organs, 
resulting in intimate fusion of the involved structures, and rendering it 
difficult sometimes to differentiate between the two organs. Occasionally 
they appear as a tubo-ovarian tumor or a fused inflammatory mass, 
which may contain serous fluid or pus. 




Fig. 335. — Double Tubo-ovarian Collection. 

Physical Signs. Tubal inflammation has no characteristic symptoms. 
If a patient has had an acute pelvic inflammation, characterized by ex- 
treme tenderness in either pelvic region, and aggravated by motion, it is 
justifiable to conclude that the possible pelvic peritonitis had its origin 
in a tubal inflammation. When each menstrual period is followed by 
pain and tenderness in the inguinal regions, tubal inflammation is very 
probable. A normal tube is not usually palpable. In diseased conditions, 
however, especially when the tube has become thickened by salpingitis or 
parenchymatous inflammation, it may be recognized as a more or less 
thickened cord which slips under the finger and is quite sensitive. When 



CER\^X AND BODY OF UTERUS. 377 

hyperplasia of its connective tissue occurs, the tube is felt as a contracted, 
distorted, nodular mass, closely associated with the uterus and frequently 
fixed firmly in the pelvis. When the abdominal end is closed, the tube 
may present an enlargement increasing from the uterus outward, some- 
thing like a bell-retort or gourd in shape, or resembling a sweet potato 
or sausage or sausage-like links. 

Diagnosis. Whtn the uterus is fixed, with extensive peritoneal inflam- 
mation on either side, it will be found, in the majority of cases, that the 
tubes were the source through which the infection reached the perito- 
neum. Normally, in a thin patient, the tubes are not palpable. Inflam- 
matory changes, however, rendering the tubes resistant and stiffened, 
make them recognizable as a cord-like structure projecting from each 
side of the uterus. When the tubes become occluded at their abdominal 




Fig. 336. — Hydrosalpinx. 

ends and fill with secretion, they are more and more retort-shaped, that 
is, larger at the external portion and narrowing toward the uterus. A 
tumor of such a shape, and quite movable, is most frequently a hydro- 
salpinx. (Fig. 336.) At times, pus-tubes may be free from adhesions, 
but generally an infection so virulent as to induce pus-formation causes 
a perisalpingitis and an agglutination to the surrounding structures — 
even absolute fixation of the pelvic structures. An inflamed tube, free 
from adhesions, is likely to drop into Douglas' pouch. The change in 
its circulation frequently fixes it to the posterior surface of the uterus, 
the sides of the rectum, or the opposite ovary and tube, forming a large 
mass filling up the pelvis (Fig. 335.) Such conditions are recognized 
readily by bimanual palpation. It is important, however, that this 
should be done with great caution, as frequently the sacs are so thin, that 
any undue pressure causes rupture and the escape of their contents into 
the peritoneal cavity, starts a general infection followed by peritonitis. 
The association of an ovary in a mass of this kind, forming a tubo-ovarian 
abscess, is not recognized readily always. A tubo-ovarian cyst is deter- 
mined more readily by the increase in size, and the greater spherical 
character of the external end of the sac, associated with a bell or retort- 
like shape as we approach the uterus. 

Prognosis. Tubal inflammation always should be considered a 
source of danger. Even its mildest forms should necessitate resort to 
treatment, in order, if possible, to arrest the progress and limit the ex- 



Z1^ 



GYNECOLOGY. 



tension of the inflammation. When associated with pelvic peritonitis, 
the extensive infection, especially the streptococcic form, is one of the 
most dangerous lesions with which we have to deal. The cure of a 
patient, with diseased ovaries and extensive suppuration of the tube, in 
the sense of restoration of her functions, is absolutely impossible. While 
the patient may recover her health and comfort, she is crippled for life, 
because her powers of procreation are destroyed. 
Treatment. (See Section 248.) 



"Af'Pf /''-^X 




Fig. 337. 



-Double Pyosalpinx, Showing Adhesions to the Rectum, to the Uterus, and, on 
the Right, to the Appendix. 



248. Inflammation of the ovary occurs in two forms: oophoritis, 
involving the structure of the organ; and peri-oophoritis, where the process 
is confined to the surface. A hyperemia or congestion of the ovary may 
arise as a result of infection. This may be so aggravated as to lead to 
rupture of vessels. The occurrence of hemorrhage into the structure of 
the ovary produces small blood-clots in the organ, known as ovarian apo- 
plexy, or a large collection of blood, an ovarian hematoma. The hemor- 
rhage may be so severe as to destroy the ovary and even rupture its coat, 
and result in a serious internal hemorrhage. Oophoritis is an interstitial 
inflammation of the ovary, which may be either acute or chronic, septic 
or gonorrheal. It is characterized by all the signs of inflammation, hyper- 



CERVIX AND BODY OF UTERUS. • 379 

emia, swelling, increase in size of the vessels, extravasation of blood, and 
later, pus-formation. This may involve only a small portion of the ovary 
or the entire organ may become the seat of an abscess. The origin of 
the infection frequently occurs in a corpus luteum, so we have what are 
known as corpus luteum abscesses. In such the walls of the abscess 
may be recognized on microscopic section by the wavy elevations of the 
inner wall. The acute form of the disease is most frequently the result of 
infection, which gains admission through lesions of the vagina, of the 
uterus (subsequent to labor or abortion), surgical operations, or an acciden- 
tal injury. Infection may reach the ovary through the continuous mu- 
cous membrane of the tube or by way of the lymphatics or blood-vessels. 
Often in fatal cases the ovary will be found very much enlarged, soft, 
and sloughing, and containing small extravasations of blood or pus; or, 
small collections of pus will be found in the connective tissue and struc- 
ture of the ovary; or a single large abscess may exist, equal in size to a hen's 
egg or even larger. The larger abscesses may be produced by suppuration 
of an ovarian cyst. Suppurating ovaries generally become adherent to 
the neighboring structure, and, if the walls are thick, the pus may remain 
quiescent, thus being the cause of a chronic state of ill health. However, 
the pus may escape by rupturing into the bowel, bladder, or vagina. 
The cavity thus emptied may shrink and ultimately disappear, while a 
state of chronic ill health will still continue. An inflamed or cystic ovary, 
adherent to the inflamed tube, frequently loses the intervening wall and 
forms a cavity, which is known as a tubo-ovarian cyst or tubo-ovarian 
abscess. Coalescence of both ovaries and tubes in such a sac may result 
in the formation of a tumor which fills up the pelvis. The formation 
of an abscess in the ovary is not always associated with peri-oophoritis. 
Some years ago I saw in consultation, and subsequently operated upon 
a patient in whom the temperature had risen to 104° F. some three weeks 
following delivery. Careful examination failed to reveal any increase in 
size of the uterus or anything to indicate that the uterus was the seat of 
disease. Some enlargement of the ovary upon the left side, which, how- 
ever, was free from adhesions, led me to open the abdomen. The left 
ovary was the size of a small orange. It was found to be free from any 
adhesions, but there was a small flake of lymph on one side which cor- 
responded with similar material in the orifice of the tube. The tube 
itself was not enlarged nor did it show any signs of an inflammatory con- 
dition. The ovary was afterward removed and, when opened, contained 
within a thin shell some thick, greenish pus. The subsequent conva- 
lescence of the patient was uninterrupted. 

In chronic oophoritis the connective tissue is greatly increased, caus- 
ing contraction, destruction of the follicles and compression and arrest 
of development of the stroma, while the epithelium of the free surface 
is the longest preserved. The latter may present extensive fissures, 
as a result of the contraction. In chronic inflammation the tunica 
albuginea becomes so greatly thickened, that it does not readily rupture 
with the development of the Graafian follicle. Consequently the follicle 
increases in size, and the ovary presents a large number of cysts, pro- 



38o 



GYNECOLOGY. 



ducing the condition known as cystic degeneration of the ovary. 
Oophoritis serosa is another form of chronic inflammation of the ovary. 
In this the inflammation is chronic in development and duration, 
and in the majority of cases curable if properly treated. It may be 
a sequel of fevers, sometimes is associated with mumps, and may 
follow a passive gonorrheal infection. The ovaries become swollen, 
exceedingly tender, and frequently prolapsed. When the disease is of 
long duration the ovaries are greatly swollen, quite smooth, shiny, and 
almost translucent. Folds and cicatrices are obliterated completely. 
Various changes in the ovaries are said to be due to cirrhosis. I have 
frequently seen ovaries which were pronounced cirrhotic, but which I 
could not regard otherwise than as physiologic. The term is only ap- 
plicable to cases in which the ovary has undergone contraction to such a 
degree as to result in the destruction of its glandular tissue and decided 
decrease in size of the organs. 




Fig. 338. — Peri-oophoritis. Tube and Ovary Encysted. 



Peri-oophoritis is a condition characterized by the deposition of inflam- 
matory material upon the surface of the ovary. The surface epithelium 
is destroyed and is likely to be followed by true oophoritis. Peri-oophor- 
itis, like simple oophoritis, is frequently a part of a widely extended inflam- 
matory process, which may involve uterus, oviducts, ovaries, pelvic 
peritoneum, and cellular tissue. (Fig. 2)2)^') Generally it results from 
an extension of infection from the tubal orifice to the pelvic peritoneum, 
although it may follow an abscess of the ovary. Usually the end of the 
tube is adherent to the ovary in this form of inflammation, and it may be 
the forerunner of a tubo-ovarian abscess. The inflammation varies from 
a few bands of adhesions which bind down the ovary and tubal orifice, 
possibly occluding the latter, to a mass of exudation which completely 



CERVIX AND BODY OF UTERUS. 38 1 

obscures both and forms so intimate a fusion as to render difficult the 
line of demarcation between these organs. 

The chief function of the ovary, apart from any supposed internal 
secretion, is to provide a site for the perfect development and maintenance 
of healthy ova, and to permit them, under circumstances as yet unde- 
termined, to pass into the mouth of the oviduct. Peri-oophoritis neces- 
sarily interferes with this process, by the presence of adhesions about the 
ovary or the consequent induration of its tunic. An ovum escaping from 
a matured Graafian follicle will be barred from entrance into the oviduct 
by adhesions which fix the fimbriated orifice or envelop the ovary. Such 
adhesions are a cause of severe suffering, especially when they limit the 
free mobility of the ovary and fix it subject to pressure, behind the uterus, 
over the rectum, or where intestinal adhesions subject it to constant 
dragging and tension by intestinal peristalsis. An ovary fixed in the 
retro-uterine pouch, with an overlying retroverted uterus, is a continual 
source of distress. Its position, independent of the adhesions, causes 
congestion from the obstructed circulation, while the pressure of feces or 
the impinging organ of the male during coition augments the discomfort. 

Symptoms. Oophoritis exhibits no characteristic symptoms. Even 
in cases of acute septic poisoning nothing will be present which can be 
said to be an absolute indication of ovarian lesion. In the less severe 
form of inflammation we may recognize symptoms which we could justly 
attribute to ovarian disease, but they are so intimately associated with 
those caused by disease of the oviducts that differentiation becomes diffi- 
cult. Pain is the only persistent symptom in all varieties of pelvic inflam- 
mation, and the site to which it is referred bears no constant relation to the 
affected organ. Though the entire pelvic region may be the seat of pain, 
we are unable definitely to distinguish the exact origin of pain and say 
whether it is due to affections of the tube, ovary, peritoneum, broad 
ligament, body of the uterus, cervix, or independent of disorder in any 
of them. This can be appreciated readily when it is remembered that 
the nervous distribution of the various organs is derived from a common 
sympathetic center. As in every inflammatory condition, pain is aggra- 
vated by pressure, so in such processes of pelvic structures pain is magnified 
by pressure and motion. The pain is distinguished from that of true 
dysmenorrhea by the fact that it is an exaggeration of the distress and is 
felt between the periods, while dysmenorrhea is purely a menstrual pain. 
Not infrequently patients will assure us that the only time they are free 
from discomfort is during the menstrual flow. Pain may persist subse- 
quent to coition as a result of congestive tension. When produced by 
intra-abdominal pressure and increased by standing, pain is greatly 
relieved by assuming the recumbent position. Ovarian pain is directly 
aggravated by pressure over the organs through the vagina or rectum, 
as during coitus, an examination, or the passage of large fecal masses. 
Such symptoms of pelvic disease, as amenorrhea, menorrhagia, or leu- 
korrhea, are not characteristic of oophoritis. Peri-oophoritis causes pain 
which is more or less distinctly localized at the pelvic brim, and extends 
down the corresponding thigh. Not infrequently pain is experienced in 



382 GYNECOLOGY. 

the breast on the same side. The inflammation may extend from the 
surface of the ovary into its substance and cause changes in its stroma, 
dropsy of its follicles, or hemorrhage, resulting in cystic degeneration, in 
one case, and in the other, in hematoma or apoplexy of the ovary. The 
wide distribution of neurotic symptoms must not be overlooked. The 
local pelvic lesion may be a minor one. To oophoritis or uterine displace- 
ment are often attributed symptoms which are the result of fissures of 
the cervix, mobility of the kidney, enteroptosis, gastroptosis, or even 
central lesions of the nervous system, which will peisist after the sup- 
posed local lesion has been cured or removed. Such experiences are a 
source of great disappointment to the gynecologist, as sometimes relief 
is obtained, and at others pain and distress continue or are even 
aggravated. 

Diagnosis. Inflammatory processes of the ovary present no constant 
characteristic clinical picture. Infection rarely confines itself to the 
ovary, consequently the symptomatic phenomena are modified by the 
circumjacent inflammatory changes. The recognition by vaginal or 
rectal palpation of a tender body, somewhat enlarged, which still retains 
the shape of the ovary, adds certainty to the diagnosis. The presence of 
adhesions or exudate will render its determination difficult and make it 
doubtful how much the swelling is due to the ovary, the tube, or the ex- 
udate. In acute conditions or in hyperesthetic patients an anesthetic 
will prove of value. Where the obscurity of the condition cannot be 
overcome, a preliminary vaginal or abdominal incision may be necessary 
in order to determine the proper operative procedure. 

Treatment of Inflammation of the Appendages. In the great majority 
of chronic inflammations of the uterine appendages the affection of the 
ovaries and tubes is so closely related that I deem it better to consider their 
treatment under one section. The first aim in the treatment is the pre- 
servation of function in the affected organs. The second, the restoration 
of health to the patient. Treatment may be either medical or surgical. 
The medical or nonoperative treatment consists in rest in bed and in 
keeping the patient absolutely quiet. Free purgation with salines should 
be established in order to make the intestines drain the peritoneal cavity 
and relieve the congestion. The diet should be restricted and cold should 
be applied to the external surface. In the acute stage the ice-bag is of 
value, and this should be kept more or less continuously applied. It 
decreases the congestion, limits the exudation, lessens the danger of sup- 
puration, and promotes absorption. After the more acute symptoms 
have subsided the treatment still further may be promoted by pressure, 
using three to five pounds of shot in a bag. This is applied over the in- 
flamed, indurated tissues. The pressure is increased and its position 
changed as maybe demanded. Probably, unless suppuration has occurred, 
resolution will Idc accomplished. Absorption may be promoted still further 
by such counter-irritants as small blisters, painting with iodin, croton oil, 
or inunctions of dilute ointment of the mercuric iodid (a dram of the 
official ointment to an ounce of lanolin). Occasionally ice will cause 
discomfort and heat be more grateful to the patient. A flaxseed poultice. 



CERVIX AND BODY OF UTERUS. 383 

or more agreeable and more easily applied, is a piece of spongio-pilin, 
wrung out of hot water, placed over the abdomen and covered with a dry 
cloth. A hot water bottle over this removes the necessity of changing 
the dressing frequently. 

One or two drams of ichthyol to the ounce of lanolin may be rubbed 
on the lower part of the abdomen in addition to the pressure suggested. 

Hot vaginal douches should be given, and rectal enemas of a pint to a 
quart of hot water, retained as long as possible, will be beneficial. These 
are more effective than hot vaginal douches as the heat comes into nearer 
contact with the inflamed surfaces, and can be retained longer. Internal 
medication should be largely supporting. The patient should be pro- 
tected carefully from exposure or over-fatigue. During menstruation, she 
should be confined to her bed. After the more acute stages have sub- 
sided, besides douches and enemas, she may take a hot sitz bath for 
fifteen to thirty minutes daily. If acute symptoms and suppuration do 
not occur, the adherent ovaries and tubes may be set free by pelvic massage. 
The structures are lifted up with one or two fingers within the vagina 
and manipulation over the abdomen is employed, gradually pressing in the 
fingers, following the lines of cleavage and lengthening the bands of ad- 
hesions to promote their absorption by stretching and irritation. The 
congestion and pain in chronic inflammation of the ovary frequently may 
be greatly lessened by the administration of fluidextract of gelsemium in 
five drop doses three times daily. Great prudence must be exercised in 
the administration of anodynes. Patients may easily acquire the morphin 
or opium habit, and the drug, instead of being a servant attains the posi- 
tion of master, and the patient is enslaved to a drug from which 
emancipation is exceedingly difficult. While, in an acute attack, a dose 
of morphin may be necessary to allay violent pain, in the majority of 
cases the early and continuous administration of the salines with the 
application of the ice-bag will be effective in arresting severe pain, or, 
at least, making it endurable. The measures which we have already 
discussed are in the line I have denominated the first aim in the treat- 
ment of lesions of the uterine organs — that is, to retain and maintain 
the functions of the organ. 

Surgical measures do not necessarily exclude this first aim, but on 
the contrary, may assure its accomplishment when established early and 
efficiently. Delay will often favor the development of conditions which 
necessitate more serious procedures. Operative treatment with a view 
to maintenance or restoration of function is known as conservative treat- 
ment. Where the sacrifice of the appendages is considered necessary, 
in order to save life or ensure good health, the procedure is known as a 
radical one. Conservative treatment may consist in breaking up adhe- 
sions; reopening the orifice of the tube; salpingostomy; or partial resection 
of the tube itself, thus shortening it and permitting the removal of such 
portions as are prejudicial to health. (Figs. 339 and 340.) Conservation 
includes also the resection and removal of diseased portions of the ovary, 
with the endeavor to retain a sufficient portion of it, to insure the continu- 
ance of ovulation and menstruation. In chronic oophoritis, marked by 



384 



GYNECOLOGY. 



thickening of the tunica albuginea and development of small cysts in the 
ovary, a resection or removal of the more diseased portion will frequently 
result in such metabolism as to restore the remainder to a more normal 
state. Wherever conditions will permit the retention of a portion of 
ovary the continuation of menstruation and ovulation have a marked 
influence on the general morale and nervous condition of the patient. 



tube:-. 




Fig. 339. — Resection of Tube. 




Fig. 340. — Operation of Resection of Tube Completed. 



The retention of the whole or part of an ovary is desirable even when it 
is necessary to remove both tubes, because it insures the continuation of 
ovulation and menstruation. The surgeon must be governed by the 
physical condition of the organs under his consideration. The abdomen 
should remain unopened unless palpable disease of the uterine appendages 
can be determined. Operations for pain without ovarian enlargement, 
will be attended with no favorable result. Where the disease is extensive 



CERVIX AND BODY OF UTERUS. 385 

and ovaries and tubes have undergone destruction, the removal of these 
organs oftentimes will be the only procedure to afford any hope for res- 
toration of the comfort and health of the patient. In suppurative con- 
ditions where the ovary also is involved in the inflammatory process 
the better plan of procedure will be the complete removal of the ovary 
and tube. In one of my patients the left ovary and tube were so extensively 
involved that their removal was indicated. The right tube was con- 
siderably enlarged. Its wall, several times its ordinary thickness, con- 
tained pus. The left tube and ovary having been removed, the right tube 
was dissected from the cornua of the uterus and the opening in the broad 
ligament closed with a continuous catgut suture, thus controlling hem- 
orrhage. The ovary, presenting no marked change, was permitted to 
remain. Such operations are exceedingly difficult sometimes, as on open- 
ing the abdomen the tube and ovary, with the fundus of the uterus are 
fixed in the pelvis in close association with coils of intestine, omentum, 
and the parietal peritoneum. Where sepsis is recent, it is often neces- 
sary to consider the advisability of removing the uterus as well as the 
appendages. When the abdomen is opened, every structure should be 
inspected carefully and examined by touch. Adhesions should be sep- 
arated and proper care exercised to insure control of hemorrhage. Oc- 
casionally the broad ligament will be so contracted from inflammatory 
changes that it will be impossible to lift the structures out of the wound, 
when the broad ligament should be resected with the ovary and tube. 
Ligation may be avoided by seizing the bleeding vessels with hemo- 
static forceps, after which the wound in the broad ligament can be closed 
with a continuous catgut suture so introduced that each turn or second 
turn shall lock the preceding stitch and thus ensure against hemor- 
rhage and prevent undue distortion of the broad ligament. After the 
more critical operations, and sometimes prior to them, the patient 
may be greatly benefitted by the rest treatment introduced by S. 
Weir Mitchell. It consists in the isolation of the patient, careful 
study of her condition, and the improvement of her general nutrition. 
The patient should be kept absolutely in bed; her secretions made nor- 
mal and her diet restricted, possibly at first to milk. Later, feeding should 
be forced. Graduated exercise should be advised, supplemented-by the 
employment of massage and electricity. By these means the elements 
of the blood are restored and the patient gradually regains her strength 
and health. 

249. Pelvic inflammation is a comprehensive term. It is neces- N 
sary, at the outset, to limit it to the conditions which we intend it shall 
include. Inflammation of the individual pelvic viscera has been dis- 
cussed, so this term will be confined to inflammation which involves the 
cellular tissue and the peritoneum. It consequently includes those affec- 
tions described as pelvic cellulitis and pelvic peritonitis. 

These conditions have been designated as peri-uterine inflammation; 

by some writers of distinction, notably Virchow and Matthews-Duncan, 

the terms parametritis and perimetritis have been used — the former to 

indicate inflammation of the cellular tissue; the latter, of the peri- 

2q 



^86 GYNECOLOGY. 

toneum. These terms are objectionable for the following reasons: 
First, they are so nearly alike in sound that it is difficult for the student 
to avoid confusion in their use, and the subject is rendered more diffi- 
cult of comprehension. Second, a difference, which does not exist in the 
anatomic relations of the peritoneum and cellular tissue to the uterus is 
implied. The pelvic connective tissue and the pelvic peritoneum are 
in equally close contact with the uterus. It is distinctly objectionable, 
therefore, to consider one as an inflammation around the uterus and 
the other as an inflammation near it. Third, the conditions are de- 
scribed as associated with the uterus, while they may exist in all the 
tissues of the pelvis,, and are not necessarily uterine in their origin. 

Careful investigation of the pathology of these conditions by autopsy, 
and extended study during abdominal procedures in active stages of 
disease, show how easily such erroneous views could arise. 

Bernutz and Aran, of France, many years ago demonstrated the true 
nature of pelvic inflammation. The practice of abdominal surgery has 
abundantly confirmed their theory by affording opportunity for compar- 
ing physical signs with actual pathologic changes. 

Varieties. Pelvic inflammation, as we have described it, is properly 
divided into inflammation of the cellular tissue (pelvic cellulitis) and 
inflammation of the peritoneum (pelvic peritonitis) . It must not be under- 
stood in these definitions that the demarcation is sharply defined, 
for, in practice, inflammation is not confined to a single or specific struc- 
ture. They indicate simply that the inflammation predominates in the 
structure named. 

250. Pelvic cellulitis, parametritis, or peri-uterine phlegmon is an 
inflammation of the pelvic cellular tissue. It may be either primary or 
secondary: i. e., it may have originated in the cellular tissue or may have 
reached it by extension from the neighboring structures. The primary 
inflammation is an acute infective disease which differs in no respect from 
acute inflammation of the connective tissue in any other portion of the 
body. Chronic pelvic cellulitis is always a secondary affection, and may 
or may not have been preceded by an acute attack. The pelvic con- 
nective tissue is not a special structure, but a portion of that wide system 
of mesoblastic connective tissue which surrounds the great vessels of the 
trunk and accompanies their branches from origin to termination. This 
connective tissue is found in the pelvis, partly in the form of a loose areolar 
network, partly in the more condensed form of fascia. It surrounds all the 
blood-vessels, nerves, and lymphatics, as well as the uterus, and serves as 
investing sheaths for them outside the pelvic cavity. It is closed off from 
the perineum and ischiorectal fossa by the pelvic fascia, a strong aponeu- 
rosis, which is attached to the pelvic wall between the pubic bones and 
bodies of the ischia, and along that thickening of the obturator fascia 
known as the white line. The fascia passes as a continuous layer 
over the levator ani and coccygeus muscles to the vagina in front, 
and to the rectum and coccyx behind. It blends closely with the 
vaginal orifice, behind the pubic symphysis, as the triangular ligament. 
Inflammatory exudations of the female genital organs above the 



CERVIX AND BODY OF UTERUS. 



6^/ 



vulva are situated above this strong fascia. The exudate with such a 
boundary below has the peritoneum for its superior limitation. This 
boundary, however, is less abrupt, as its connective tissue layer is con- 
tinuous with the subserous connective tissue of the parietal peritoneum of 
the abdomen. With the exception of the fundus of the uterus, it forms 
a layer beneath the entire pelvic peritoneum — both parietal and visceral. 
The so-called uterine ligaments contain more or less connective tissue 
between their peritoneal folds, and in certain situations it is abundant; 
for instance, around the supravaginal portion of the cervix, and along the 
base of the broad ligaments and between the bladder and symphysis 
pubis. In the latter situation it contains a varying quantity of fat in its 
meshes. 

The ofhce of this tissue in the pelvis, as elsewhere, is to protect and 
support the other structures, performing a passive mechanical function. 
It affords a cushion which prevents injury of the viscera (Schaefer) . The 
connective-tissue layer, between the vagina and peritoneum posterior 
to the uterus, generally does not measure more than 1/3 of an inch in 
thickness, but in pregnancy its thickness is greatly increased. During 
the progress of development of a pregnant uterus the broad ligaments are 
gradually drawn upward, until at the completion of the pregnancy they 
lie in the iliac fossa, above the brim of the pelvis, while no peritoneum 
dips into the lateral parts of the pelvis. The space thus vacated is filled 
with connective tissue, which is enormously increased during the later 
months of pregnancy. Freund describes a form of cellulitis w^hich affects 
more particularly the fatless connective tissue, or fascia, which he calls 
parametritis chronica atrophicans circumscriptum et diffusum. Cellulitis 
is a very common complication of pelvic peritonitis, involving particularly 
the uterosacral ligaments and peritoneal folds. Schultze calls this para- 
metritis posterior: uterosacral cellulitis is more accurate. Cicatrization 
of the ligaments following such inflammation causes traction upon the 
upper part of the cervix, and is a very common cause of dysmenorrhea, 
and sterility. As a result of the contraction of the tissues the uterus may 
be anteflexed and drawn to one side or backward, thus producing a path- 
ologic anteflexion. By compression of the vessels and nerves the uterus 
and ovaries may become atrophied. Cellulitis may exist with or without 
suppuration. When suppuration does not occur, an exudation results 
in the connective tissue, which becomes edematous, and subsequently 
more or less organized, firm, and hard, causing pressure upon the 
vessels and nerves which pass through it. The changes in this struc- 
ture are similar to those which take place in cirrhosis of the liver or 
kidney. 

Etiology. Primary pelvic cellulitis is always a result of sepsis. Ready 
entrance for septic material is afforded through lacerations of the cervix uteri. 
These injuries may be caused by the use of forceps, and, if kept aseptic, 
heal readily. In the nullipara, cellulitis may arise from the same causes 
as pelvic peritonitis (such as exposure to cold during menstruation) being 
then generally associated with pelvic peritonitis; and from surgical opera- 
tions which open the connective tissue (as in the removal of large uterine 



300 GYNECOLOGY. 

polypi) and afford an opportunity for cellulitic infection. The danger 
is especially great when the growths are expelled or removed while in a 
state of necrosis. There is a certain amount of lymphangitis then, with 
which the lymphatic glands may be implicated. Cellulitis may develop 
from disease in the bladder. As a result of such irritation the connective 
tissue outside the bladder thickens. This thickening passes outward and 
forward, and, in ultimate atrophy, may cause uterine displacement in the 
opposite direction. From the rectum, the causative irritation may be 
dysenteric. A pelvic cellulitic abscess is frequently so situated as to 
render it more than probable that the hypogastric glands are involved. 
Inflammation occurs more rarely in the cellular tissue than in the pelvic 
peritoneum. With the advent of suppuration an abscess follows, gen- 
erally of large dimensions, although occasionally, several abscesses may be 
found in close apposition. 

Symptoms. In puerperal cases the cellulitis is generally ushered in 
with a rigor or chill about the second or third day after delivery, although 
occasionally it may occur later. In nonpuerperal cases the interval 
between infection and the first manifestation of symptoms is rarely more 
than one or two days. The occurrence of the chill has produced the 
Lelief that the inflammation arises from exposure to cold; simultaneously 
with the chill occurs an elevation of temperature, a rapid pulse, but rarely 
pain, unless the peritoneum is involved. When suppuration occurs, the 
most marked symptom is the progressive emaciation associated with 
pallor or earthy sallowness of the skin. The skin is harsh, dry, and covered 
with bran-like scales from the fine desquamation. Peritonitis may 
complicate the condition and will be indicated by the frequent vomiting 
of a dark-green fluid. Vomiting will be excited by the ingestion of the 
smallest quantity of anything, even liquids. The patient looks ill, loses 
her appetite, and suffers from marked debility and severe mental depres- 
sion. She becomes very irritable. If the exudation extends to the fascia, 
over the iliacus and psoas muscles, and particularly if the connective- 
tissue elements between these muscles are involved, the patient will lie 
upon her back with the leg of the affected side flexed and the thigh bent 
upon the trunk. The symptoms are those of a subacute form of septice- 
mia. Pain and local signs may be so slightly marked as to lead the con- 
dition to be unsuspected or overlooked. 

Physical Signs. In the early stages of an acute attack the physical 
signs are but slightly marked. All that will be noticed by digital examina- 
tion is that the vagina is hot and its vessels are pulsating. In a few hours 
there are indications of an inflammatory exudate. There is a doughy 
sensation and fullness on one side of the uterus and in the iliac fossa. 
This may extend partly around the cervix, and subsequently become 
hard and indurated. If the poison has entered through a wound in the 
cervix, the latter becomes less movable. The supravaginal tissues on 
the affected side are tender, more or less hard, and unyielding. There 
is a bulging at the side of the uterus, and the lateral fornix on that side 
is apparently obliterated. (Fig. 341.) We rarely find both sides of the 
uterus affected at the same time, but occasionally the whole supravaginal 



CERVIX AXD BODY OF UTERUS. 



389 



portion of the cervix may be embedded in a thick collar of indurated 
tissue, which more or less completely surrounds it. Generally the disease 
spreads laterally along the base of the broad ligament to the tissue be- 
neath the reflection of the peritoneum on the anterior abdominal wall. 
When this occurs, a uniform hardness or resistance is felt in the abdominal 
wall beneath the muscles. This may assume the form of a broad band , half 
an inch to 2 inches or more in width, lying along the upper border of 
Poupart's ligament. Occasionally the exudation spreads upward and 
outward from above Poupart's ligament into the iliac fossa. This exu- 
dation may extend in one of two ways : (a) Either by following the course 
of the lymphatics which run from the uterus outward beneath and between 
the layers of the broad ligament to the glands and lumbar region; (b) or 




Fig. 



by lines of cleavage in the cellular tissue of the pelvis. In the latter it 
frequently passes backward, producing an exudation about one or both 
uterosacral ligaments in the tissue enveloping the rectum, and lines the 
posterior pelvic wall beneath the peritoneum. The rectum will be felt 
wholly or partly surrounded by a belt of exudation, which forms a bridge 
or an arch. If suppuration does not occur, the exudation becomes ab- 
sorbed, and, in uncomplicated cases, the hardness may so far disappear 
as to leave no subsequent trace. In not a few cases pelvic cellulitis re- 
sults in the formation of an abscess. The situation of the abscess and 
the direction in which it may be expected to extend depend upon the 
situation and the extent of the inflammatory exudation. If seated in the 
base of the broad ligament and passing forward beneath the peritoneum, 
to the anterior abdominal wall, an area of induration may be noticed 
above Poupart's ligament. Suppuration is indicated by the occurrence, 
over the indurated area, of edema in the skin, which pits on pressure; 



390 



GYNECOLOGY. 



by deep-seated fluctuation, especially under bimanual examination; 
and by the eventual pointing of the abscess a little above Poupart's liga- 
ment. Often the pus can be detected before it reaches the surface by 
passing the tip of the finger carefully over the induration, when a softened 
point will be recognized in the surrounding hardness. Unfortunately 
as we have already noticed, pelvic cellulitis may extend backward instead 
of forward, when, if suppuration follows, an abscess forms beneath the 
peritoneum covering the back of the pelvis. Such an abscess has no 
direct access to the free surface, relief is much longer delayed, and exten- 
sive burrowing follows which can extend into the iliac fossa and the loin, 
particularly when it is seated in the posterior wall. The abscess may 
point at the iliac crest, or may sometimes leave the pelvis by the sciatic 
notch and follow the course of the sciatic or gluteal vessels. Again, it 
appears in Scarpa's triangle, having followed the side of the femoral 
vessels. By whatever route the abscess leaves the pelvis it will follow 
the prolongation of the connective tissue upon the blood-vessels or the 
ureter, rather than that of the nerves or tendons. When pus burrows 




Fig. 342. — Exudation of Cellulitis over Rectum. 



along the psoas muscle, it comes, not from cellulitic a'bscess, but from 
dead bone, and this is an important fact to keep in mind. 

I saw with the late Dr. Kappes a patient who had been confined 
about six weeks previously. She was suffering from what appeared to be 
a subacute attack of septicemia. She was lying with her limbs drawn up, 
and complained of severe pain in the abdomen, extending into the groin. 
On examination, induration could be recognized extending from the left 
lumbar region to the groin. Vaginal examination disclosed the uterus 
freely movable, with no induration about it nor in the pelvis, until the 
finger was passed well above the briin, when the indurated psoas muscle 
was recognized. On inquiry this patient gave a history of having fallen 
in a sitting position, during the third month of pregnancy, while walk- 
ing on stilts to amuse her children. She suffered more or less discomfort 



CERVIX AND BODY OF UTERUS. 39 1 

during the remainder of the pregnancy. An incision was made on the 
left side over the crest of the ilium and the peritoneum was pushed for- 
ward, when the tissue of the psoas muscle was found infiltrated with pur- 
ulent material. It was hoped that the vent thus afforded would give 
the patient relief. She improved for a few days, when pain occurred upon 
the opposite side, where a similar condition was found. 

We not infrequently hear of cellulitic abscesses opening into the rectum, 
vagina, or bladder, but these cases are doubtful, when considered in the 
light of the pathology of pelvic inflammation. They are more than likely 
cases of intra-peritoneal suppuration which have originated either in dis- 
ease of the Fallopian tubes or of the ovaries. An abscess will usually 
point between the seventh and twelfth weeks. 

In discussing pelvic disease we should not overlook a peculiarly 
malignant form of inflammation, mostly occurring in puerperal women. In 
this multiple abscesses in the connective tissue are found associated 
with other lesions significant of the virulence of the infection. Many of 
these abscesses are so small as easily to elude detection. The condition 
is known as diffuse pelvic suppuration, and has all the characteristics 
of phlegmonous erysipelas. The tissues become edematous and of a 
livid hue. Suppurating thrombi are found in the veins and the lymphatics 
are acutely inflamed. Occasionally, the ovaries may be found in a state 
of suppuration. Associated with this condition are all the symptoms of 
acute infection in its most virulent form. 

Diagnosis. The absence of pain frequently permits considerable 
progress before the existence of the condition is suspected. Puerperal 
women, because of the tenderness of the external genitals and the presence 
of the lochial discharge, are very averse to vaginal exanination. If the 
puerperium pursues a normal course, this aversion should be respected, 
but it cannot be too strongly asserted that examination should be made 
whenever symptoms of pyrexia supervene and the ordinary course of 
convalescence is interrupted. A temporary disturbance of temperature 
and of pulse-rate may result from such causes as constipation, excite- 
ment, and mammary engorgement. Unless such conditions can be 
recognized as provocative of the disturbance, if the abnormal symptoms 
are persistent, or especially if the lochia is offensive, a thorough examina- 
tion not only of the vagina, but of the interior of the uterus, is required. 
During the first ten days subsequent to delivery the uterus can be explored 
readily without artificial dilatation. If a portion of placental tissue or 
a decomposing blood-clot is found, it should be removed, and the uterine 
cavity should be cleansed and disinfected. Ordinarily the symptoms 
will be relieved promptly. If they are not, the examination wdll have 
revealed the probable cause of the disorder, and simultaneously will 
permit any swelling or other morbid condition of the pelvic tissues to 
be detected. A few days after the onset of the attack the physical signs 
of cellulitis will be so marked as to render the diagnosis certain, and a 
laceration of the cervix or of the vagina will be disclosed as the probable 
gateway for the entrance of the infection. Occasionally the first indica- 
tion of cellulitis will be an impaired mobility of the cervix upon one side. 



392 GYNECOLOGY. 

on which tenderness and swelling will be marked. Later, this inflamed 
structure becomes stiff, and passes to well-defined hardness. The cel- 
lulitis may be situated to one side of the cervix or may extend along the 
base of the broad ligament of the affected side. The lateral fornix of 
the vagina will be completely obliterated. When the inflammation ex- 
tends backward, vaginal examinations of the posterior wall will reveal 
a diffuse fullness and hardness on the affected side, which is still further 
demonstrated by rectal examination. In the rare cases in which the 
broad ligament itself is affected the diagnosis is determined by finding the 
mobility of the body of the uterus impaired, and a more or less flattened 
mass of induration upon one side, which is continuous with the uterus. 
Excepting the plane of tissue between the cervix uteri and the bladder, 
the cellular area of one side of the pelvis is practically shut off from that 
of the other. Hence, we find pelvic cellulitis is, for the most part, uni- 
lateral. The differential diagnosis of pelvic peritonitis will be discussed 
later. 

The only other conditions with which cellulitis can be confounded are 
hematoma of the broad ligament and myoma of the uterus. In hematoma 
there is an effusion of blood into the connective tissue. This forms a 
slightly movable, somewhat flattened tumor alongside of and continuous 
with the uterus. The history of the case and the absence of symptoms 
of severe illness will generally serve to distinguish it. It occurs suddenly, 
from rupture of a pregnant tube or of a varicose vein in the broad ligament. 
In either case the onset is marked by violent pain, faintness, syncope, 
and usually vomiting. In pregnancy of the tube one or two menstrual 
periods will have been passed, and the pain will be situated in the lower 
part of the abdomen (generally on one side) with irregular uterine bleed- 
ing. The effect of such an outpouring of blood upon the temperature 
and pulse is transient. The temperature is not elevated. If infection 
occurs, suppuration results, and the symptoms then are similar to those 
of pelvic abscess from cellulitis. Myoma can rarely be mistaken for 
cellulitis. Error is possible only in those rare cases in which the myoma 
develops laterally between the layers of the broad ligament and forms a 
more or less hard tumor directly continuous with it. Should the myoma 
be complicated by a localized peritonitis, or the tumor become inflamed 
or gangrenous, diagnosis may be difficult. In the posterior wall error 
is scarcely probable, for large inflammatory exudations into the connec- 
tive tissue behind the uterus are extremely rare. In the anterior wall the 
signs of cellulitic exudation between the bladder and the upper part of 
the cervix are well marked and characteristic. 

Prognosis. The disease terminates in recovery, except in the diffuse 
variety, when it is a part of a general septic process. With subsidence 
of fever the exudation is gradually absorbed, and under favorable circum- 
stances entirely disappears in a few weeks. Cellulitis uncomplicated by 
peritonitis leaves no unpleasant results, no adhesions nor displacements. 
Consequently, its existence is no bar to subsequent pregnancy. If 
fever continues longer than five or six weeks, suppuration has probably 
resulted. The duration and progress of the illness will largely depend 



CERVIX AND BODY OF UTERUS. 393 

upon the direction the pus takes. Generally it points above Poupart's 
ligament, where it can be easily and satisfactorily opened. Such cases 
invariably do well. In the rare cases when it occurs at the back of the 
pelvis, pus is longer in reaching the surface, and may burrow in different 
directions. Such cases often last a long time, and are likely to be com- 
plicated by extension to the peritoneum. A^Hien resolution and the 
absorption of the inflammatory processes are slow, the exudate will become 
organized, and cause cicatricial contraction and resulting displacement 
of the uterus. Such contractions also lead to atrophy of the uterus and 
ovaries. The obstruction of the circulation produces localized conges- 
tion and even inflammation, and causes disturbances of menstruation, 
such as menorrhagia, dysmenorrhea, and sterility. It is necessary, then, 
to be guarded in our promises of complete recovery. 

Treatment. A description of the disease and its causes emphasizes 
the importance of preventive treatment. This consists in careful atten- 
tion to the principles of asepsis or surgical cleanliness in all midwifery 
cases and in surgical manipulations. If freedom from infection could be 
insured, pelvic cellulitis would disappear. \\Tien the disease is once 
developed, medication, either internal or external, has but little influence. 
The most important indication is to avoid doing the patient harm. 
Particular care should be exercised in the administration of opium and 
antipyretics. The former agent is generally given as a matter of routine. 
Opium adds to the disturbance of the already obstructed digestive 
functions and aggravates constipation — one of the difficulties which it is 
important to obviate. Opium or morphin should be given only in cases 
complicated by peritonitis, in which it is absolutely necessary to afford 
relief. Similarly, antipyretics should be reserved for the rare occasions 
when the temperature is so high as to constitute a source of danger in 
itself. A simple saline mixture, potassium citrate, or small, frequently 
repeated doses of magnesium sulphate should be given until the bowels 
are freely evacuated. Care should be exercised to avoid fecal accumula- 
tion. The question of feeding is of equal importance: farinaceous diet 
in the acute stages, with meat, eggs, and easily digested food in the later 
period of the disease. The tendency to emaciation calls for generous 
feeding. In the early stages of the inflammation an ice-bag over the 
abdomen will limit the congestion and the amount of inflammatory 
exudate. When the ice-bag is uncomfortable or causes distress, hot 
fomentations should be applied. Hot vaginal douches, at a temperature 
of from iio° F. to 115° F., are advocated by Emmet, although the influence 
they exert is doubtful. When pus forms, the case should be dealt with 
according to recognized surgical principles. The abscess should be 
opened as soon as fluctuation is detected or there is the faintest indication 
of pointing, and drainage should be instituted for a few days. If the ab- 
scess points in the vagina, it must be opened there. Most of the fluctuat- 
ing swellings felt through the vaginal roof are not cellulitic abscesses, 
but come from an entirely different direction. While not generally 
recognized as the proper plan of treatment, yet, without question, the 
course of an abscess can be shortened or suppuration prevented by making 



394 GYNECOLOGY. 

an incision in the infected cellular tissue through the vagina as soon as 
the swelling about the uterus can be recognized. The infected area 
should be broken into with the finger, and a gauze drain inserted to 
afford vent for the discharge. The drainage thus secured will frequently 
obviate the occurrence and danger of suppuration and prevent the ex- 
tension of inflammation to the pelvic peritoneum. If the patient lies 
with the thigh flexed on the body, the limb should be exercised by lifting 
the foot with the hand under the heel two or three times a day sufficiently 
to straighten the knee. This will prevent permanent contraction and 
stiffening of the joint. 

Chronic pelvic cellulitis, as already asserted, does not exist as an in- 
dependent affection. Not infrequently it follows purulent salpingitis 
or other intrapelvic suppurative inflammation, and involves only the 
parts immediately contiguous to the inflamed structures. The induration 
which it causes, introduces for a time, an element of obscurity in the diag- 
nosis of deep-seated inflammatory lesions of the pelvis. It is rarely at- 
tended with cellulitic abscess, and is characterized chiefly by edema and 
small-cell infiltration of the connective tissue. Its absorption and the 
mobility of the uterus may be promoted by the practice of pelvic massage. 
(Section 105.) When cellulitis has existed sufficiently long to result in 
atrophy of the uterus or ovary, treatment exerts but little effect. 

251. Pelvic peritonitis, perimetritis, perisalpingitis, or peri- 
oophoritis, is an inflammation of the peritoneum situated within the 
pelvis. It occurs more frequently than pelvic cellulitis; indeed, more 
frequently than any other form of inflammatory disease within the pelvis. 
In the great majority of cases it is an infective process, due either to the 
presence of micro-organisms or to the effect of their chemic products. 
In the main its action may be regarded as beneficial, as it is one of nature's 
efforts to resist or to do battle with the invading foe by erecting barriers 
around the diseased area. These barriers serve to narrow or to confine 
the field of invasion, and shield the neighboring structures from damage. 
Treves asserts that the purpose of peritonitis is to save and not to destroy 
life. Unfortunately, the poison may be virulent, exist in so large a quan- 
tity, or the resistive powers of the patient be so enfeebled that we are 
neither able to limit nor to guide the inflammatory process to a successful 
issue. 

Etiology. Probably pelvic peritonitis never occurs as a primary 
disease, but always as a complication of a preexisting disorder. Occa- 
ionally, however, it is the first recognized expression of such disease. 
The symptoms of peritonitis are so severe that attention is at once aroused, 
while the condition from which it originated may have been so insidious 
as to have been overlooked. From want of knowledge, then, of the 
previous disease we are often compelled to ignore the exciting condition, 
and to say that the patient suffers from pelvic peritonitis. Is it surpris- 
ing that the original condition was formerly unrecognized and the disease 
denominated idiopathic peritonitis supposed to result from a slight injury 
or from exposure to cold ? It is true there are stfll cases in which we are 
unable to discover the preexisting disease, but such have become less and 



CERVIX AND BODY OF UTERUS. 395 

less frequent. Now failure to determine the cause of pelvic peritonitis 
is the result of defective observation and of want of knowledge. 

The most frequent cause is sepsis; next, gonorrheal infection. The 
micro-organisms principally concerned in the development of infection 
are the streptococcus, the staphylococcus, the gonococcus, the bacillus 
coli communis, and the bacillus tuberculosis. The propagation of these 
infectious micro-organisms is favored by parturition, abortion, instru- 
mental examination, and surgical interference. Other causes are in- 
flammations of the appendix, intestinal perforations, abdominal lesions, 
rupture of an ectopic gestation, hematocele, ovarian abscess or hematoma, 
and malignant disease. 

Infection generally reaches the peritoneum in one of three ways: 
first, by the continuous mucous membrane through the uterine cavity 
and tubes; second, by the blood-vessels; third, by the lymphatics. 

Tubal disease is the most common cause of pelvic peritonitis, and 
should receive first consideration. The mucous membrane of the Fallo- 
pian tube is continuous with that of the uterus, and at its abdominal end 
opens into the peritoneal cavity. 

The continuity of the tubal mucous membrane with that of the uterus 
and vagina subjects it to continual danger of infection. The tendency 
of every acute infective endometritis, whether septic, gonorrheal, or tu- 
bercular, is to extend to and involve the tube. The relation of the tubal 
mucous membrane to the peritoneum, in infection of the former, favors 
its extension to the latter. This risk is further aggravated by the anatomic 
position of the tube in woman. No other mucous membrane is similarly 
situated. The uterine cavity, when inflamed, naturally drains into the 
vagina through the external os; but the tube has its most constricted 
portion toward the uterus, where the lumen of the canal is but large enough 
to permit the passage of a bristle. A slight amount of swelling will be 
sufficient to close the uterine end, when the only other outlet of the tube 
is into the peritoneum. The absence of a suitable outlet for morbid 
secretions of the tube and the continuity of its mucous membrane with 
the peritoneum render inflammatory affections of the canal of especial 
importance and make pelvic peritonitis a frequent consequence of 
salpingitis. 

A prompt result of peritonitis from tubal infection is closure of the 
abdominal ostium of the tube by adhesions or by inflammatory changes 
in the fimbriae. The tube then becomes filled with retained secretion, 
and is the center for an inflammatory process which extends through the 
wall to the neighboring tissues, especially the peritoneum. If this exten- 
sion is not an immediate occurrence, the tube is subject to frequently recur- 
ring inflammatory attacks from slight causes. When the retained secretion 
consists of pus the liability to recurring attacks of pelvic peritonitis is 
much greater than when the accumulation is serous or mucopurulent. 
To this liabflity is added the danger of ulceration and thinning of the tube- 
wall and the possibility of pus escaping into the peritoneal cavity by per- 
foration or rupture. Frequently the ovary becomes infected from the 
tube, suppurates, and affords a fresh source of danger. Both inflamed 



396 GYNECOLOGY. 

tube and ovary may act as further sources of peritonitis, but sometimes 
the tube, after infecting the ovary, recovers and is no longer a focus for 
infection. Infection of the ovary is very apt to occur v^^hen the latter has 
been the site of cystic disease or when a Graafian follicle has ruptured 
recently. The most frequent mode of infection is through a cyst-wall 
which has become adherent to a diseased tube. Sometimes the infection 
occurs through an ulcerative process which permits the tubal contents 
to enter the cyst suddenly by perforation of the cyst-wall. Tubo-ovarian 
abscess is thus explained. Such an infection may produce an attack of 
peritonitis more violent than any preceding. 

A more alarming attack of peritonitis is engendered by the escape, 
through ulceration, of the contents of a suppurating tube or ovary into 
the peritoneal cavity. Fortunately, such an occurrence is rare. The 
thinned wall of such a collection is a menace which places nature upon 
her guard and stimulates her to form adhesive barriers which will limit 
the space into which the rupture occurs and favors the formation of an 
intra-peritoneal abscess. Such an abscess may enlarge rapidly, and, if 
the patient survives, may burst into one of the neighboring viscera, into 
the peritoneal cavity, or externally, according to its situation. Suppura- 
tion of an ovarian cyst may be independent of infection through the tube; 
occasionally, it probably occurs from the proximity to the rectum or in- 
testine of an inflamed growth. The cyst is more vulnerable to such infec- 
tion when it has been exposed to injury or subjected to bruising, as in 
labor. 

Peritonitis may be favored by twisting of the pedicle of an ovarian 
cyst. This accident can result in strangulation, intracystic hemorrhage, 
inflammation, or necrosis of the growth, according to the amount of 
strangulation. The accident is particularly apt to occur during 
parturition. 

The presence of puerperal sepsis should be regarded as demanding 
careful investigation. New pelvic growths, by their mere presence, 
may engender peritonitis. This is common in ovarian tumor. The 
tumor varies greatly in the probability of its producing peritonitis. 
Uterine fibromata may attain a large size without adhesions unless 
degenerative processes set in, while a papilloma of the ovary or tube, 
dermoids and malignant diseases usually are associated with extensive 
peritonitis. 

Severe septicemia may follow abortion, parturition, or surgical 
manipulations, and, instead of being confined to the uterine mucous 
membrane, can be carried at once by blood-vessels or lymphatics to the 
peritoneum, and generate a diffuse septic infection in the pelvis. Such 
a peritonitis may become localized in the pelvis or may prove fatal by its 
rapid extension to the general peritoneum. 

Clinical experience has demonstrated that injury alone will cause 
peritonitis only when the hand or instrument inflicting the injury is surgi- 
cally unclean. The truth of this assertion is illustrated by the infrequency 
with which extensive operative manipulation within the peritoneal cavity 
is followed by inflammation, and by the frequent attacks of virulent and 



CERVIX AND BODY OF UTERUS. 397 

fatal peritonitis following slight injuries in efforts to produce abortion. 
It is, without question, a mere problem of infection. Usually in the 
latter the operator is ignorant or reckless. 

Complications during parturition may cause peritonitis. The shape 
and size of the normal pelvis is adapted to the passage of the normally 
constructed child at full term, and is without extra accommodation. Any 
encroachment upon the pelvis by tumor, growth or malformation affords 
an obstacle which renders passage through the canal possible only at the 
expense of injury or bruising. This may result in loss of vitality of 
tissue or growth, and thus render the structures more susceptible to the 
influence of pathogenic micro-organisms. 

Pelvic cellulitis, it has been said, is generally secondary, but 
still it may precede the peritonitis. This is particularly true of sup- 
puration. 

Pelvic hematocele is a source of peritoneal inflammation. The 
irritation induced by the blood diffused into the peritoneal cavity causes 
exudation and adhesive peritonitis. The blood-serum may be roofed in 
beneath adherent omentum and coils of intestine, when the peritonitis 
limits effusion and promotes its subsequent absorption. 

Inflammation of the vermiform appendix, or appendicitis, is a not 
infrequent cause of pelvic peritonitis. Its normal situation is in the right 
inguinal region, just above the brim of the pelvis, but instances have oc- 
curred in which it was found lying within the pelvis. In right-sided 
inflammation of the pelvic peritoneum an inflamed appendix always 
should be regarded as a possible source of the infection. An abscess 
formation may follow, which wfll fill up Douglas' pouch. In many 
cases it is difficult to determine whether the appendix or the right tube is 
the original source of infection. 

Pathologic Anatomy. Inflammation of the peritoneum may be serous, 
adhesive or suppurative; acute or chronic. As it most frequently origi- 
nates from infection through the tubes, therefore, the tubes and ovaries 
are implicated. It begins as a congestion or hyperemia of the serous 
surface, with cloudy swelling of the endothelium. The membrane, 
instead of being smooth and glistening, becomes dull, dry, clouded, 
and slightly roughened with plastic lymph, which is poured out between 
its adjacent surfaces. The adhesions thus produced are its most 
characteristic feature. In recurrent attacks we find additional ad- 
hesions. Serum exudation becomes encapsulated. It is found in the 
meshes of the connective tissue, may fill the cul-de-sac or pelvis, posterior 
to the uterus, or it may be encysted to one side. Such collections may 
simulate a cyst. When the exudation thrown out is considerable, it 
may form a distinct coating, which may be peeled from the surface of 
the peritoneum. These lymph coagula are also found floating in the 
serum, and, as the fluid becomes absorbed, this coating stiffens the 
peritoneum, and, with the induration in the subjacent cellular tissue, 
causes the hardness which is one of the striking characteristics of chronic 
pelvic peritonitis. 

Usually these indications of inflammation are most strongly marked 



398 GYNECOLOGY. 

about the fimbriated ends of the Fallopian tube, and diminish as they 
pass from it. When the inflammation has originated from some other 
cause, such as an inflamed appendix, the alteration and adhesions are 
most dense at the seat of origin. Thus, a Fallopian tube, when it becomes 
inflamed and increases in weight, drops from its original position, so 
that it is found upon the floor of the lateral fossa of the pelvis, in the pouch 
of Douglas, or adherent by its fimbriated end to the ovary or to the side 
of the pelvis. Occasionally the two tubes meet, and the distal ends be- 
come adherent to each other behind the uterus. At other points the direc- 
tion of the tube may differ in two sides of the body. One side is bent 
like a horseshoe, while the other terminates against the lateral wall of 
the pelvis, to which it is adherent by its abdominal end. If the uterus 
is lifted out of the pelvis by pregnancy, the tube may be found situated 
above the brim, close to the border of the psoas muscle. The ovary 
generally is found implicated in the mass of inflammation which has ex- 
tended from the tube. When this inflammation has existed for some 
time, we find the ovary in a cystic state, considerably enlarged. These 
changes result from the effect of the surrounding peritonitis. 

In chronic cases the peritoneum is lifted up in places, by circumscribed 
collections of serous fluid in its meshes. These swellings vary in size 
from a pea to a large orange. They possess no pathologic importance, 
but often increase the difficulty in arriving at an accurate diagnosis. A 
mass formed by an inflamed tube, ovary, and broad ligament not infre- 
quently is found adherent to the posterior pelvic wall and rectum. Some- 
times a coil of intestine or a portion of omentum may intervene, when the 
parts are so entangled in an extensive mass of exudation as to cause great 
difficulty in outlining and determining their relations. The body of 
the uterus is enveloped in a mass of adhesions or is completely free. 
When the lesion from which the peritonitis has originated is purulent, 
peritonitis is apt to be purulent also, and, instead of an accumulation of 
serum, pus or intrapelvic abscesses are found. Occasionally, suppurative 
peritonitis exists. The latter occurs only in cases of exceptional viru- 
lence, or from sudden bursting into the peritoneal cavity of a pus- 
collection which was situated in an ovary or tube. 

Intraperitoneal abscesses may be single or multiple. They generally 
originate by the rupture of a suppurating Fallopian tube or by the dis- 
charge of pus through its abdominal ostium into Douglas' pouch or into 
a space bounded by adhesions. Both tubes may thus discharge into 
a common receptacle, which is most generally Douglas' pouch. A tense, 
fluctuating swelling is formed, easily felt through the depressed vaginal 
roof, which, by pressure against the intestine, causes more or less obstruc- 
tion. Purulent inflammation of the tube leads early to closure of the 
abdominal ostium, when the pus is confined within the tube, and forms 
what is known as a pyosalpinx. An intraperitoneal abscess or 
general peritoneal infection may then be induced by infection through 
the tubal wall, or by the bursting of the pyosalpinx from ulceration 
within, or by the spread of infective processes to the ovary, causing it to 
suppurate. 



CERVIX AND BODY OF UTERUS. 399 

An intraperitoneal abscess walled in by adherent viscera may run an 
acute course or may be retained for a long time, causing few indications 
of its presence, if any. One of two things is likely to occur, however: 
either the abscess gradually dries up and disappears, or its walls undergo 
ulceration and its contents escape into the bowel — usually the rectum, 
sigmoid flexure, or colon — or into the vagina, the bladder, the general 
cavity of the peritoneum, or some part of the abdominal wall. The 
most frequent exit is through the intestine. The other routes are ex- 
ceptional. Such abscesses differ markedly from cellulitic abscesses, 
and will quickly disappear when they have once found an outlet. The 
latter discharge their contents imperfectly. A troublesome sinus remains 
for years, producing serious ill health. iVmong the secondary changes 
resulting when salpingitis is unilateral is an extension of the peritonitis 
to the other side of the pelvis, involving the healthy uterine appendages 
in a mass of adhesions which complicate the function of both tube and 
ovary. Such a condition may be followed by hydrosalpinx. 

Hydrosalpinx may result as a sequel of salpingitis, but is less frequent 
than pyosalpinx. 

Effusion of blood within the tube (hematosalpinx) often arises as a 
consequence of tubal gestation, but occasionally may be independent of 
the latter. 

Symptoms. The first characteristic of acute pelvic peritonitis is 
pain in the lower part of the abdomen, which is sudden in its onset. For 
a few hours it is extremely severe, associated with fever, with increased 
rapidity of pulse, and often with vomiting. An early symptom is more or 
less intestinal distention, which may be general or localized. Following 
the acute pain, movement is attended with great suffering, because of 
the tender, inflamed parts, and the patient is generally obliged to remain 
in bed for a length of time dependent upon the severity of the attack. 
Rigors are infrequent, unless the condition is part of a diffuse septic 
inflammation or the result of intraperitoneal rupture of a pyosalpinx 
or a suppurating ovary. Constipation is usual. Pain precedes defeca- 
tion and micturition, owing to the contiguity of the inflamed part to the 
rectum or bladder. Not infrequently the pain is greater at the completion 
of micturition. The patient generally assumes the recumbent posture, 
with the limbs flexed, and guards the abdomen against the pressure of 
clothing or contact with the hand. In subacute or chronic cases pain 
in the back and inability to undergo physical exertion are experienced. 
Menstruation is more profuse than normal, often painful. Very trifling 
causes will result in recurrence of the attacks. This is particularly true 
when the chronic pelvic peritonitis is maintained by the presence of pelvic 
suppuration. Recurrence of pain and abdominal tenderness are more 
reliable indications of the presence of pus than is elevation of temperature. 
Not infrequently a large quantity of pus may be found in the pelvis of a 
patient who has either a normal or a subnormal temperature. Patients in 
whom extensive suppuration exists are found emaciated and incapacitaed 
for work or exercise. In the worst cases the patient will be bedridden. 
The amount of sufl'ering depends upon the nature and extent of the disease 



400 GYNECOLOGY. 

and upon the social position of the patient; in other words, upon the de- 
mands that are made upon her activity. In an acute attack the abdom- 
inal muscles are kept rigid over the affected parts. This rigidity is due to 
muscular contraction, and is beyond the control of the patient. Occa- 
sionally, by abdominal palpation a definite swelling can be recognized. 
This is particularly true when the mass is situated above the brim of the 
pelvis, has attained a large size, or presents an encysted exudation of 
serum or pus in front of the uterus or against the pelvic wall. Occasion- 
ally the abdominal enlargement will be due to the presence of serous 
fluid. When depression of the vaginal roof occurs, it will not be lateral, 
but central, because the accumulation of effusion, serous or purulent, 
is in Douglas' pouch. Upon vaginal examination the parts may be very 
tender, with a sense of resistance, or the uterus is pushed forward. After 
subsidence of the acute symptoms a careful bimanual examination, for 
which an anesthetic may be required, often will reveal in the posterior 
fossa of the pelvis the presence of a fixed, irregular, tender swelling. This 
begins at the uterine cornu as a cylindric body, equal in thickness 
to a lead-pencil; it may be rolled between the fingers, but may sud- 
denly become thicker a short distance externally; it curves itself, 
may completely reverse its direction, and finally ends behind the cervix 
uteri in the pouch of Douglas. A Fallopian tube can be adherent to 
the ovary, which is embraced within the concavity of its curve, and sur- 
rounded on all sides by a thickened, adherent peritoneum. The uterus 
is not always displaced, but is often found retroverted or retroflexed, and 
adherent in its abnormal position. Again, it may be pushed forward 
by a mass of effusion in Douglas' pouch. The shape and consistence of 
the swelling vary in different cases, as the tube may be soft, sausage- 
shaped (particularly when its abdominal ostium is occluded), or it may be 
distended mostly at the outer end, which gives it the shape of a retort. 
Occasionally it is irregular, distended from sacculation, thrown into 
knuckles or prominences, bent upon itself with sausage-like convolutions 
produced by intervening constrictions. Its consistence depends upon 
the extent to which the walls of the tubes have become thickened and 
upon the induration of the surrounding peritoneum. 

Diagnosis. Peritonitis may be confounded with hematocele and 
cellulitis. Pelvic hematocele is distinguished readily by its clinical 
history, slight febrile disturbance, history of a possible tubal gestation, 
severe pain attending the rupture of the latter, and the subsequent bloody 
discharge from the uterus. Later, pelvic hematocele may be followed 
by peritonitis. 

The distinguishing features between peritonitis and cellulitis are as 
follows : 

Peritonitis. Cellulitis. 

1. Inflammation is confined chiefly to the i. Inflammation principally affects the 

pelvic peritoneum. pelvic cellular tissue. 

2. Inflammation is bilateral. 2. Inflammation is unilateral. 



CERVIX AND BODY OF UTERUS. 



401 



Differential Diagnosis. 



Peritonitis. 



Cellulitis. 



Its onset is sudden, with severe pain. 

Both legs are drawn up. 

A firm, flat effusion surrounds the 
uterus or a mesial bulging is pro- 
duced by serous effusion in Douglas' 
pouch; the vaginal portion of the 
cervix is of normal length. 

The inflammation does not extend 
along the round ligament and iliac 
fossa, but it may affect the entire 
peritoneum. 

The uterus is displaced forward or 
backward. 

Vomiting is frequent. 



1. Its onset is insidious, pain not marked. 

2. One leg is drawn up. 

3. A firm effusion bulges usually into the 

fornix of the one side; the cervix is 
apparently shortened on the affected 
side. 

4. Exudation, or pus, spreads in definite 

directions, and usually is localized. 



5. The uterus is displaced to one side. 

6. Vomiting is infrequent. 



Prognosis. The mortality of peritonitis is much higher than that of 
cellulitis. Even when the patient recovers, the after-effects are more 
troublesome, and frequently the sequels are sufficiently serious to entail 
a life of chronic invalidism. The disease from which the peritonitis 




Fig. 343. — Induration from Peritonitis. 

originates remains after the subsidence of the acute attack, and con- 
stitutes a focus from which subsequent attacks are likely to result, either 
from changes in the diseased tissues or from external agencies. Recur- 
ring attacks of peritonitis are more likely to occur when associated with 
the presence of pus, either in the form of pyosalpinx, suppurating ovary, 
or intraperitoneal abscess. 
26 



402 GYNECOLOGY. 

The damage done to the uterus, ovaries, and Fallopian tubes, particu- 
larly to the latter, by the obstruction of the abdominal ostium, necessarily 
causes sterility. If the gradual absorption of the morbid products per- 
mits the occurrence of conception, the continuation of pregnancy to full 
term may be rendered impossible by the inability of the organ to become 
enlarged because of extensive adhesions. It is not possible, however, 
to say that pregnancy cannot occur, for experience has demonstrated that 
even after the most virulent peritonitis the parts may so recover themselves 
as to permit of a subsequent conception. The discreet practitioner will 
consequently hesitate to assert positively that the patient cannot give 
birth to children. Another effect of pelvic peritonitis is interference with 
the normal action of the intestinal canal. 

The termination must depend upon the condition of the individual 
patient. 

Treatment. The first and most important aim of treatment is pre- 
vention. The large majority of nonpuerperal cases of pelvic peritonitis 
originate from a preexisting gonorrheal salpingitis; consequently the treat- 
ment should consist in the arrest of the infection before it has extended 




Fig. 344. — Induration from Pelvic Cellulitis. 

beyond the reach of local application. Unfortunately, gonorrhea is fre- 
quently regarded as an unimportant affection, although it probably 
destroys the health of a larger number of women than does the more 
dreaded poison of syphilis. The earlier symptoms of the disease usually 
pass unregarded. They are attended with but little pain — often none, if 
the urethra is uninvolved — and the significance of the purulent discharge 
is not realized. Medical advice, consequently, is unsought until the 
infection has produced serious results or has inflicted life-long damage. 
Even when advice is obtained, the disease seldom is regarded seriously, 
and vigorous treatment is not employed. A purulent vaginal discharge 
in a recently married woman should always be regarded with grave 
suspicion, and its treatment should be undertaken with a due sense of 
responsibility. 

The object of treatment should be to prevent the extension of disease 
to the tube or the development of septic salpingitis. Its occurrence means 
a focus for the continuous distribution of infection and a cause for fre- 
quently recurring attacks of peritoneal inflammation. Such invasion, as 
would naturally be inferred, is a frequent consequence of gonorrhea, but 
its avoidance requires rigid adherence to the rules of aseptic surgery and 
midwifery in the management of abortion, parturition, and surgical 



CERVIX AND BODY OF UTERUS. 403 

manipulation. Care should be exercised in the examination of patients, 
and particularly when such investigation is to be intra-uterine. 

When a patient has once suffered from pelvic peritonitis, it is ex- 
tremely important that all causes likely to provoke a relapse should be 
avoided. She should be careful in her dress, not be exposed to cold or damp, 
especially during her menstrual period, and should guard against exhaust- 
ing exercise or overfatigue. Prolonged standing is as disastrous as exces- 
sive exercise. She should be advised to secure sufficient rest, and the action 
of her bowels should be carefully regulated. Intestinal adhesions natur- 
ally aggravate the tendency to habitual constipation. Fecal accumulation 
favors development and migration through the coats of the intestines of 
pathogenic micro-organisms, hence constipation should be overcome by 
proper regimen, suitable aperients, or enemas of glycerin or of soap and 
water. The medical treatment is similar to that employed in pelvic 
cellulitis, with the exception that opium and its derivatives may be neces- 
sary. Their administration, however, should be regarded as an unavoid- 
able evil. Only small doses should be given and these discontinued 
as early as possible. Constipation should be prevented by appropriate 
aperients or enemas, or both. Accumulation of scybala is more harmful 
than active purgation. During an acute attack the patient should rest 
in bed, and the diet should be restricted to liquid or easily digested food 
at regular intervals. The pain should be relieved by the application of 
the ice-bag, or, if this is uncomfortable, by hot fomentations. Intestinal 
distention is relieved by the use of enemas. The patient will probably 
be tormented by thirst and by the desire for ice or effervescent waters. 
She will find greater relief from frequent sipping of hot water. Ice should 
be avoided, as, when once employed, it increases the thirst. The patient 
will constantly demand it, but if granted, the mouth and tongue will 
soon suffer from a severe attack of glossitis. If the enemas fail to give 
relief, an aperient should be administered — doses of calomel, castor oil, 
or, what is more efficient, sulphate of magnesium. The last may be 
given in one- to two-dram doses, dissolved in syrup of ginger and cinna- 
mon-water, every two or three hours until the bowels are freely evacuated; 
subsequently three or four times a day, as the condition may demand. 
The state of the pulse is a more correct guide to the condition of the patient 
than the temperature, and will indicate the need for stimulants. If the 
pulse shows signs of flagging, becomes thin, feeble, and intermittent, 
brandy or whiskey should be given in regular doses, diluted with five or six 
times the quantity of water, its effect being carefully watched, the dose to 
be increased or diminished according to its influence. Stimulants should 
not be allowed to take the place of food. The indications of collapse — 
coldness of the extremities, sunken features, flagging pulse, subnormal 
temperature — should be further combated by the application of external 
heat and by the hypodermatic injection of strychnin and atropin or digi- 
talin. The intensely depressing effect of intestinal distension should be 
kept in mind, and this condition should be relieved by the use of enemas 
or by the introduction of a soft-rubber rectal tube with the patient turned 
upon the side. Not infrequently, as suggested by Keith, an injection 



404 GYNECOLOGY. 

of quinin, gr. vj, whiskey, fgss, and water, fgij, repeated every hour 
until three doses have been given, stimulates the nerve-centers and in- 
creases peristalsis. The most effective enema is an ounce of powdered 
alum dissolved in a quart of hot water. This is best given with the 
patient lying either upon one side or upon her back, with the hips elevated. 
The alum enema promotes peristalsis, and, consequently, is of service 
in tympanites. Where peritonitis is established and the patient is eject- 
ing a dark-green fluid from the stomach and is unable to retain even 
liquids, the stomach should be irrigated through the stomach-tube 
with a normal salt solution. This should be repeated if the vomiting 
returns. No food, not even water, should be allowed to enter the stomach. 
Peristalsis should be quieted by injection of gr. 1/6-1/4 morphin hypo- 
dermatically, followed by gr. 1/16-1/12 of the same agent every three 
hours. The nutrition should be maintained by rectal feeding, adminis- 
tering normal salt solution three ounces, bovinine one ounce, every three 
or four hours, and, where necessary, hypodermoclysis or intravenous 
injections normal salt solution may be employed. 

The occurrence of peritonitis should lead to a careful examination 
of the pelvis, and any indication of tenseness in Douglas' pouch or about 
the cervix should be considered an indication for immediate vaginal incis- 
ion to break up the tissue and permit the fluid to escape. The opening 
should be kept patulous by the introduction of a gauze drain. Such a 
course will frequently arrest or limit the progress of the inflammation. 
The mere removal of the tension affords great relief. If an intraperito- 
neal abscess exists, such interference not only affords relief, but may an- 
ticipate its bursting into the rectum and establishing a troublesome sinus. 
Unless such conditions can be determined, however, it is wiser to defer 
surgical intervention until the acute symptoms have subsided. If the 
attack is the first the patient has had, and the swelling is so slight as to 
indicate a probable nonpurulent inflammation, operative interference 
should not be advised. If the patient has had similar attacks repeatedly, 
and swelling of such a size is found as to render it probable that in its 
midst there is an occluded, distended Fallopian tube or an enlarged, 
cystic ovary, operation should be urged. Such a mass, with the recurring 
attacks, almost positively indicates the presence of pus; and where pus is 
present, surgery is absolutely indicated. It is impossible, of course, to 
lay down positive rules; every case must be decided individually. A 
woman from the laboring-class cannot afford to spend as much time in 
invalidism as a woman in better circumstances. Advancing peritonitis 
with evidence of pus or inclination to suppuration should be subjected 
to drainage. An incision above, and parallel to eachPoupart's ligament, 
another, well back in each lumbar region and in the vault of the vagina, 
will afford, through ropes of gauze, vent for the accumulating effusions. 
The operative procedure in cases demanding such drainage should be 
done with the greatest expedition and with no effort to flush out the peri- 
toneum. This can be accomplished more effectively by what is known as 
the Murphy treatment with the patient in the Fowler position. The 
patient is placed in a semi-sitting position with the nozzle from a fountain 



CERVIX AND BODY OF UTERUS. 405 

syringe or suitable apparatus in the rectum. The fountain is raised but 
a little above the level of the body, the tube pinched so that the fluid 
(normal salt solution) is delivered at the rate of thirty minims to a dram 
to the minute. Where the fluid is retained, three to six pints are thus 
introduced into the circulation in each twenty-four hours and the influence 
in stimulating elimination is extremely gratifying. In cases drained 
in this manner the peritoneum is flooded freely. In enfeebled patients, 
the instfllation can be conducted with the patient in the recumbent 
position, but the drainage is not so satisfactory. 

When operation has been decided upon as necessary, the method of 
procedure still remains undetermined. Abdominal section, being the 
older and more generally adopted procedure, wfll be described first. 
(For the preparation of the patient see Section 131.) The patient is 
placed upon the operating table, preferably one by which the Trendelen- 
burg posture can be secured, and an incision from 2 1/2 to 3 inches long 
is made in the median line, beginning an inch above the symphysis pubis. 
The operator must remember the possibflity of adhesions between the 
intestines, the omentum, and the anterior abdominal parietes, and should 
proceed carefully as he approaches the peritoneal cavity. Generally 
the omentum is adherent to the mass in the pelvis, over the surface of the 
uterus, the tubes, or the ovaries. The first step is to separate these ad- 
hesions and to free the omentum and adherent coils of intestine. The 
omentum and intestines are drawn upward to express the matted contents 
of the pelvis beneath them. When the patient is in the flat position, the 
operator must be guided almost entirely by the sense of touch. In the 
Trendelenburg posture the manipulations can be conducted by sight. 
Following the fundus of the uterus as a guide, the operator endeavors 
with the tips of the first two fingers to enucleate the diseased uterine appen- 
dages from their adherent surroundings. The uterine fundus may be free 
or implicated in the adherent mass. In the latter case its identification 
may be exceedingly difficult, rendering it necessary for an assistant to pass 
one or two fingers into the vagina to elevate and press the uterus against the 
cervix. The fundus is thus identified. The affected tube, on one side, 
is traced out from the uterine cornu and made to serve as a guide when 
searching for planes of cleavage. If it turns backward and becomes lost 
in the adherent mass, the safest way is to keep the fingers close to the pos- 
terior surface of the uterus, and to trace the adherent mass downward to 
Douglas' pouch. In breaking up the adhesions it is necessary to separate 
the mass from the walls of the bowel, including the anterior wall of the 
rectum. It is often advisable to have an assistant pass his forefinger into 
the rectum, partly to facilitate the separation by steadying the bowel, 
partly to ascertain where the bowel is and whether the manipulation is in 
dangerous proximity to it. The separation of these adhesions in Douglas' 
pouch is generally the most difficult part of the operation. Indeed, I 
know of no operation more difficult than to break up adhesions which 
have existed for a long time between knuckles of intestine and the fundus 
of the uterus or the ovaries and tubes. The separation is to be continued 
posteriorly from below upward. When the mass has been cleared from 



4o6 



GYNECOLOGY. 



its posterior and inferior attachments to the uterus and to the uterine 
appendages of the opposite side, there still remain adhesions to the back 
of the broad ligament, which has become more or less folded over the 
diseased parts, and forms a deep, concave surface on its posterior aspect. 
This concave surface' has to be unfolded in order to permit the mass to be 
brought into view and the broad ligament below it to be transfixed. This 
separation can be accomplished by working from below upward, and 
should be continued until the ovary and tube remain attached to the 
uterus and broad ligament by their anatomic connections only. The 
pedicle is then tied in the same manner as in the removal of the normal 
ovary and tube for the relief of myoma. The appendages on the opposite 




Fig. 345." — Intestines Held Back by Gauze. Patient in Trendelenburg Posture. 

side are examined, and are removed or left, according to their condition. 
If merely adherent, the operator may content himself with separating the 
adhesions. 

During such manipulation it is not unusual to find an escape of pus 
which may be independent of any fault of the operator. Often it is 
difficult to accomplish without rupture the separation of adhesions around 
the ostium of a suppurating tube or the enucleation of a suppurating and 
adherent ovary the wall of which is thinned and nearly ready to burst. 
Fortunately, unless the pus is unusually virulent, no serious harm results. 
However, in such cases, we should always exercise care to use several 
layers of gauze pads to wall off the general peritoneum and intestine to 
prevent their being soiled. (Fig. 345.) Occasionally, in severe cases, 



CERVIX AND BODY OF UTERUS. 407 

when the patient is much depressed, the persistence required for the sepa- 
ration of extensive adhesions would so prolong the operation as to en- 
danger the hfe of the patient. Then it may be necessary to content our- 
selves with mere emptying and draining of the suppurating cavity. The 
greater the experience of the operator, however, the less frequent will be 
the incomplete operation. Separation of adhesions between different 
parts of the intestinal canal other than the rectum should be made as 
much as possible under the eye, and any injuries to these structures should 
be repaired immediately. The inexperienced operator should be careful 
not to mistake a thickened and adherent intestine for an inflamed Fallo- 
pian tube. This mistake may be avoided by following the tube toward the 
uterus before an effort is made toward its separation. 

During the performance of these operations the general peritoneum 
should be carefully protected by drawing back the intestines and omentum, 
and retaining them with gauze or gauze sponges, so that they shall not be 
soiled by rupture of an abscess cavity. When the operator and his assist- 
ants have been unable to protect the intestines from contact with the 




Fig. 346. — Three-pronged ^'ulseliunl. 

contents of the abscess, I think it better to irrigate the abdomen with hot 
normal solution, 105° to 112° F., and thus complete the peritoneal toilet 
rather than to attempt to accomplish it by dry sponging. In such cases 
the belly cavity may be left filled with the salt solution. Drainage must 
be decided by the indications of the individual case. The larger the 
experience of the operator, unless he is particularly prejudiced, the less 
will he be likely to use drainage. Even in the most virulent cases, with 
extensive adhesions, irrigation of the cavity with a large quantity of normal 
salt solution, repeating it before the cavity is closed and leaving a consider- 
able quantity of fluid within the abdomen, dilutes any poison that may 
remain and renders it less active or likely to produce deleterious effects. 
In this way drainage may be avoided. In suppurative peritonitis McCosh 
suggests intra-intestinal injections of saline cathartic. He cleanses the 
peritoneal cavity thoroughly with irrigation instead of sponging. Be- 
tween one and two ounces of a saturated solution of magnesium sulphate 
is introduced through a hollow needle into the small intestine at a point as 
high as possible in the jejunum or ileum. The needle-puncture is closed 
by a Lembert suture. The action of the saline produces free watery 
discharges, and thus makes the intestine act as a drainage-tube for the 
peritoneal cavity. When drainage is used in suppurative cases, the gauze 
or wick drain, in which a number of strands are introduced into different 



4o8 



GYNECOLOGY. 



parts of the abdominal cavity, is the preferable method. If the ends are 
carried well around the side of the body and are surrounded by cotton and 
gauze at a point below the level of the internal ends, we then secure a 
siphon-like action, which drains the cavity more effectually. 

Fowler suggested elevation of the body of the patient so that the 
drainage may accumulate in the most dependent portion of the abdomen, 
whence it can be siphoned by a gauze wick emerging from the lower 
angle of the wound or into the vagina. This has appealed to the profes- 
sion as the most satisfactory procedure. In closure of the wound we must 




Fig. 347. — ^Vaginal Incision for Pus-collection in the Broad Ligament. 

endeavor to utilize measures that will bring together and hold in apposition 
the tissues, so that firm union may be secured and the risk of hernia les- 
sened. Various methods of procedure have been employed such as^the 
introduction of a double row of sutures or of a series of sutures, one in 
the peritoneum, another in the aponeurosis, and another in the skin. The 
difficulty in the introduction of rows of sutures, however, is that frequently 
dead spaces are left in which an accumulation of fluid occurs. This 
becomes infected later and results in the formation of an abscess, which 



CERVIX AND BODY OF UTERUS. 



409 



necessarily weakens the wall. I endeavored to obviate this difficulty by 
the employment of the figure-of-8 suture. The suture was made to cross 
just in front of the aponeurosis or that portion of the abdominal wall 
which it is most important to maintain in apposition. The figure-of-8 
suture was designed to accomplish the same purpose as a double row of 
sutures, but with the advantage that the suture could be removed. It 
was found to have a disadvantage, however. In order to secure apposition 
of the tissues, the suture was likely to be drawn so firmly as to result in a 
slough, which produced a stitch abscess. 




Fig. 348. — Incision through Vagina with Thermocautery in Vaginal Excision of the Uterus. 



I have experienced the greatest satisfaction in a combination of 
continuous chromic catgut suture with interrupted silkworm-gut sutures. 
Beginning at either angle of the wound, the catgut suture is introduced 
external to the aponeurosis upon one side of the wound, brought out in the 
peritoneum and fascia of the opposite side, and then through the edges of 
the peritoneal wound until the other angle of the wound has been reached, 
when it is brought out above the aponeurosis. Silkworm- gut sutures are 
now introduced, including all the tissues above the peritoneum, the wound 
is cleansed, and the catgut suture continued, uniting the edges of the apo- 



4IO 



GYNECOLOGY. 



neurosis, when the wound is carefully dried before the introduction of the 
last turn and the tying of the knot. Again drying the wound, the silk- 
worm-gut sutures are tied. This procedure gives secure union of the peri- 
toneum, aponeurosis, and skin with but one buried knot. When twenty- 
day catgut is used, the wound should be secured firmly against subsequent 
weakness. 

The silkworm-gut sutures serve as supports to the wound, and should 
be tied only closely enough to hold the surfaces in apposition. The 
after-treatment is similar to that of other abdominal operations. (Section 




Fig. 349.— Clamp Forceps for Securing the Broad Ligament. 

150.) The combined crescent and vertical incision ( Fig. 151), where 
large masses do not have to be removed, has given me great satisfaction. 
It greatly lessens the danger of hernia, while affording an opportunity to 
conceal an unsightly scar beneath the pubic hair. 

Vaginal Section and Uterine Castration. Many clinical observers have 
appreciated that the infected uterus, from which disease had been trans- 
mitted to the peritoneum and appendages, has continued to be a cause for 
discomfort and ill health after the secondary foci of infection — the append- 
ages — have been removed. 

Pean, in 1886, to insure relief in such cases, advocated the removal of 
the uterus through the vagina as a routine procedure in all cases in which 




Fig. 350. — Deschamps Needle Ligature Carrier. 

that organ had been involved in an infectious process. This operation 
he designated as uterine castration. Subsequently the procedure was 
popularized by the advocacy of Segond and Jacobs. The diseased 
appendages may or may not accompany the uterus in its removal. In pre- 
paring for this operation the following instruments should be sterilized: 
Three double tenacula; four vaginal retractors; a knife; one pair of straight 
scissors and one pair curved on the flat; four large and twelve small 
pressure forceps; an angiotribe; a Deschamps ligature-carrier; a needle- 
holder; needles, threaded with silk loops; chromic catgut, sizes o and 2. 



CERVIX AND BODY OF UTERUS. 



411 



The operator may also have at hand the thermocautery and a large number 
of sterile gauze sponges. The steps of the operation are similar to those 
in the performance of the ordinary operation of vaginal hysterectomy. 
The patient is prepared as directed in Section 131. She is placed in the 
lithotomy position, and the uterus is exposed by vaginal retractors, one 
anterior, a second posterior, and one on each side. These retractors 
are held by two assistants. The cervix is seized by a vulsellum or double 
tenaculum, dragged down, and a circular incision made through the vagi- 
nal walls, which will be nearer the os externum anteriorly than posteriorly. 




Fig. 351. — Dra\^'ing Down the Fundus. 



Behind, the incision extends for half an inch or more above the os. If re- 
quired, additional room can be secured in the vagina by lateral incisions 
in the vaginal w^all which extend for half an inch outward from the circular 
incision, and parallel with the broad ligament. The incision about the 
uterus often is made with the thermocautery. This has the advantage 
that, in addition to decreased bleeding, the burn prevents the surfaces 
from immediate union and affords better opportunity for drainage. 
After cutting through the vagina the tissues are pushed away from the 
cervix with the finger. The separation between the bladder and the cervix 
is accomplished by blunt dissection with the finger or some blunt instru- 



412 



GYNECOLOGY. 



ment, or by successive snips of the scissors. The late Joseph Eastman 
inserted the scissors, closed, near to the cervix and then separated the 
blades, which facilitated the dissection. The dissection can be accom- 
plished posteriorly more rapidly as there is but little danger of injuring 
the rectum. The dissection is completed front and back by opening the 
peritoneal cavity when the uterus is held by the broad ligaments, through 
which pass the uterine and ovarian arteries. The tissues upon each side 
are divided with successive snips of the scissors, and the uterine artery is 
seized with forceps as soon as exposed, or immediately when cut. The 




Fig. 352. — Application of the Clamp Forceps to the Lower Portion of the Broad Ligament. 

fundus of the uterus can then be tilted forward through the anterior 
fornix of the vagina. This permits the cervix to be carried upward. 
With the fingers passed over the fundus of the uterus, the ovary and tube 
are followed upon the tense surface of the broad ligament and dragged 
down. 

A chromic catgut ligature is carried through the ligament and firmly 
tied when the hemostatic forceps are applied above the point of ligation. 
Usually this is done first upon the left side, after which the broad ligament 
is cut between the uterus and the forceps. Readier access is so afforded 



CERVIX AND BODY OF UTERUS. 



413 



to the right tube and ovary which is treated similarly. The uterus and 
appendages thus are freed from their attachments. The remaining 
vessels are ligated. If the condition of the patient is such as to demand 
expeditious operation, the broad ligaments may be controlled by compres- 
sion forceps only, and the operation completed by simply packing the 
vagina with gauze. The gauze should be carried between the forceps 
and well over their internal ends, in order that the intestine shall not be 
injured. Pryor used strong forceps with movable handles. Forceps and 
vulva are covered with a sterile dressing and the patient is put to bed. 
The forceps should be allowed to remain for forty-eight hours, the gauze 




Fig. 353. — Ligation of the Broad Ligament in Vaginal Hysterectomy. 

for four or five days. The clamp method, while expeditious, has the 
disadvantage, however, that the tissue enclosed in the grasp of the forceps 
undergoes necrosis, and causes a disagreeable odor for two or three weeks 
subsequent to the operation. This necrotic process is a worry to the 
patient, nurse, and physician. Where several such patients are in a 
ward, the atmosphere is rendered disagreeable. There is always the 
possibility of infecting the parametrium and peritoneal cavity and opera- 
tors generally prefer to use the ligature. For a time the angiotribe was 
much used, but if the tissue has undergone inflammation and contains 
more or less exudate, the angiotribe should not be used. It crushes this 



414 



GYNECOLOGY. 



tissue, indeed almost bites it off, and therefore, does not preclude the pos- 
sibility of bleeding. In the use of the ligature care must be taken to tie it 
so firmly that it will not slip. The uterine arteries should be picked up 
separately and do not require a large mass within the ligature. 

Chromic catgut should be preferred for ligatures in the pelvis, although 
it has the disadvantage of being more apt to slip. Pelvic ligatures are 
likely to become infected. Silk engenders a profuse discharge, extensive 
granulations, and a condition which is uncomfortable for the patient and a 
source of worry to the physician. The use of the electrothermic angio- 




FiG. 354. — Upper Portion of the Broad Ligament Secured by Clamp Forceps, 

tribe as suggested by Dr. A. J. Downes, cooks the tissues to such a degree 
that hemorrhage is effectually controlled and there is no ligature to act 
as a source of irritation. This seems an ideal procedure, but it necessitates 
the use of an additional apparatus which requires skilled attention. 
When the inflammatory exudate in the pelvis has been extensive and has 
gone on to suppuration, so that we have pus-sacs in the broad ligament 
or in Douglas' pouch, the preferable plan of procedure is to make the 
incision through the posterior cul-de-sac, open, evacuate, and irrigate the 
pus-sacs before the general peritoneal cavity is opened and disturbed. 
Gauze may be packed into the pelvis temporarily during the remaining 



CERVIX AND BODY OF UTERUS. 415 

Steps of the operation. In some cases the uterus is so bound down by in- 
flammatory exudate that the dissection through the anterior fornix of the 
vagina is somewhat difficult. In these cases the operation may be ex- 
pedited by sphtting through the anterior lip of the uterus, holding each 
side of the organ with the double tenaculum, and drawing it down while 
the cervix is being split. This affords a better opportunity to observe the re- 
lation of the bladder and the uterus, and to keep within the layer of connec- 
tive tissue in the septum. Splitting the cervix and making traction upon its 
sides enable us to see the relation of the bladder and, consequently, to avoid 
injuring it. Another modification is the amputation of the cervix after 
the lower part of the broad ligament has been cut through. This, permits 
readier rotation downward of the fundus through the anterior fornix, as 
it has a shorter arc through which to rotate. The fundus of the uterus 




Fig. 355. — The Introduction of Gauze after Removal of the Uterus. 

may be rotated through the posterior fornix, but the anterior is preferable, 
because it puts the broad ligament more readily upon the stretch and en- 
ables us to find better the lines of cleavage between the tube and ovary and 
the other adherent viscera. If the ovary and tube are not readily brought 
down, or if the patient is suffering from chronic hyperplasia of the tubal 
and ovarian structures, by which these organs are often largely obliterated, 
a clamp may be applied on either side of the uterus prior to its removal. 
After its removal, more room is given to reach the appendages, but should 
the adhesions be firm and resistant, the tubes may be permitted to remain 
after breaking open and packing with iodoform gauze all pus-pockets. 
As the great majority of these cases have been infected, it is better to keep 
the wound open by packing it with iodoform gauze than to close the vagina 
and peritoneal surfaces. Landau advocates and practises the bisection 



410 GYNECOLOGY. 

of the uterus through the anteroposterior line as a preliminary. One-half 
of the organ is pushed upward, the other is drawn down. This procedure 
gives more room for the manipulation necessary in the application of 
forceps, the use of the ligature, or in crushing with the angiotribe. It 
affords better opportunity, also, for dealing with the infected tube and ovary. 
As a preliminary, the intestines and peritoneum can be protected by 
packing with sterile gauze before we proceed to enucleate or separate the 
ovary and tube. In the employment of pieces of gauze it is very important, 



Fig. 356. — Closure of the Vaginal Wound by Sutures. 

however, that the end of the gauze should be fixed with a pair of hemo- 
static forceps, as the pad is very readily worked upward into the peritoneal 
cavity by intestinal peristalsis, and may easily get beyond the reach of the 
surgeon. Nothing is more annoying than to perform an operation 
expeditiously, and subsequently have to lose valuable time in hunting 
sponges. The nurse who dispenses the sponges should do nothing else, 
and should keep an accurate account of the number of sponges she has 
given out. These should be accounted for before the operation is con- 
sidered completed. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



417 



Whenever possible the peritoneal cavity should be closed and this can 
be done unless adhesions have been very extensive. The peritoneum 
front and back should be secured to the corresponding vaginal walls, the 
stumps held by forceps above; the ligated mass is secured in each angle 
of the vagina by a suture passed through the anterior and posterior 
vaginal walls and tied over it. A pursestring suture closes the peritoneal 
space intervening. The end of each stump should then be pushed behind 
the vaginal wall and the vaginal incision closed. (Fig. 356.) 




Fig. 357. — Landau's Method of Delivering the Uterus after its Complete Median Section. 



DISPLACEMENTS OF THE PELVIC ORGANS. 

252. Displacements of the Pelvic Organs. The relations of the 
structures of the vulva are modified and distorted by hypertrophy, 
varicose veins, inflammatory exudates and deposits, edema, hernia 
and tumors. They are, however, so intimately connected with the 
deeper structures that they are not subject to anything like displacements. 
All the other pelvic structures are capable of more or less marked dis- 
placement; still all are so closely related to and dependent upon uterine 
deviations that we will proceed to the consideration of the uterus and 
its displacement as a primary subject. 

Physiologic Movements of the Uterus and the Forces by Which it is 
Sustained. The uterus is a freely movable organ. With its fundus at or 
27 



4i8 



GYNECOLOGY. 



a little above the level of the brim of the pelvis, it is suspended in the pelvis 
by the action of the uterosacral, the uterovesical, and the inferior portion 
of the broad ligaments. It occupies the axis of the pelvis, with its cervix 
directed toward the last sacral vertebra. The supports of the uterus are 
not ligaments in the ordinary sense, but consist of connective tissue, into 
and through which run prolongations from the uterine muscular structure, 
so that the organ is to some degree sustained by muscular action. This 
is evident from the fact that the organ moves upward and downward with 
every respiratory excursion, changes its position with that of the body, and 
is influenced by the distention and condition of the surrounding viscera. 
In the normal position the uterus rests forward upon the. bladder, in a 




Fig. 358. — Uterus Displaced by Distended Bladder. 

position of slight anteflexion, while the cervix is directed almost at a right 
angle to the axis of the vagina. The uterine position is markedly changed 
by the distention of the bladder, which raises the fundus and decreases the 
angle between the uterus and vagina until it becomes exceedingly obtuse 
(Fig. 358). In marked distention, indeed, the uterine axis becomes 
nearly parallel with that of the vagina. The cervix is pushed forward by 
a distended rectum. (Fig. 404.) When the rectum and the bladder are 
both distended, the uterus is elevated, and no longer finds room between 
these two viscera. It will be seen that the muscles, arranged as just 
mentioned, support the cervix. The movements of the body of the uterus 
are influenced by the broad ligaments on each side. These prevent its 
undergoing lateral change of position. The round ligaments act as stays 
to prevent it from falling backward, or draw it forward, when the bladder 



DISPLACEMENTS OF THE PELVIC ORGANS. 



419 



is emptied. The round ligaments are, of course, an insignificant force, 
but it must be remembered that the uterus weighs less than an ounce. 
It can be understood, therefore, how they serve to maintain the uterus far 
enough forward to permit the intra-abdominal pressure to be durected 
against its posterior surface. So long as the intra-abdominal pressure 
continues on the posterior uterine surface the uterus is held forward against 
the bladder. It is also important for maintenance of the uterus in its 
normal place that the muscular structure of the pelvic floor shall remain in 
normal condition. Relaxed vaginal walls or muscular structure, occasioned 
by injury to the pelvic floor in which the perineal muscles — particularly 
the levator ani — are torn through, withdraws a support, which sooner or 




Fig. 359. — Uterus Displaced by Impacted Rectum. 



later favors displacement. The normal condition of the peritoneum is a 
factor. This structure is certain to be affected by loss of muscular tone 
and of muscular support. It is not one factor, then, but several, which 
combine to maintain the uterus in its normal relations. 

Pathologic Changes and What Constitute Them. From what has been 
said of the physiologic changes of position in the situation of the uterus it 
can be seen how difficult it is to draw the line of demarcation between physi- 
ologic and pathologic changes. It may be said that when the uterus under- 
goes such changes in its structure or envelopes that it becomes stable in a 
position which is at times regarded as physiologic, it becomes pathologic 
and is known as displacement. Thus, the uterus may be pushed back- 
ward by a distended bladder, which will increase the angle between its 



420 



GYNECOLOGY. 



axis and that of the latter; but if it does not follow the bladder forward 
when that organ is emptied, the position becomes abnormal. 
These changes may result from : 

1. Neglect of hygiene, either in permitting the bladder to become 
habitually overdistended or the rectum to be loaded with fecal matter 
until the uterus is so driven back that the intra-abdominal pressure is 
no longer directed upon its posterior, but falls upon its fundus or an- 
terior surface. These changes will lead to an abnormal fixation. 

2. Inflammatory changes in the uterus, leading to increased weight of 
the organ, straightening of the body, loss of its normal curvature; and, by 
the weight, displacement of the organ forward, by which pressure is 




Fig. 360. — Scheme of Dislocated Uteri. {Dudley.) 

exerted against the fundus of the bladder. Or, again, the increased 
weight produced by inflammatory conditions causes relaxation of the 
pelvic ligaments and consequent displacement of the uterus downward and 
backward, while the body is bent upon the cervix. This bending may 
take place forward, backward, or laterally. 

3. The presence of inflammatory material in the cellular tissue and in 
the structures surrounding the uterus causes its displacement by the volume 
of exudation, and subsequent displacement in the opposite direction takes 
place by the resulting inflammatory contraction. The uterus may be dis- 
placed as a whole, although it still remains parallel to its former axis, 
causing a change of location; or, again, it may be turned upon its axis 
forward, backward, or laterally; may be bent upon its own axis; may be 
depressed downward; and may undergo torsion. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



421 



4. The presence of growths, either of uterine or external origin. 

Classification of Displacements. As may be inferred from what has 
been stated in the previous section, the uterus is capable of displacement 
upward, downward, backward, forward, and laterally, or of being twisted 
upon its axis. Upward displacement is known as ascent; downward, as 
descensus or prolapsus uteri. (Fig. 360.) The location of the uterus is 
subject to change: thus, when it is situated toward the back part of the 
pelvis, hugging closely the hollow of the sacrum, it is known as a retro- 
location; close to the symphysis pubis, as anantelocation; and toward one or 
the other side of the pelvis, as a dextro- or sinistro-locatipn. When the 
direction of the axis of the organ is changed, it is known as a version; 
with the fundus well forward, it is an anteversion; the fundus turned back- 
ward, a retroversion; and toward either one or the other side, a dextro- or 




Fig. 361. — Uterus Pushed up by Tumor in Douglas' Pouch. 



sinistro-version. The organ may be bent upon its axis, in which event the 
cervix and fundus approach each other. This bending may take place 
forward, backward, or laterally, giving rise to the terms anteflexion, 
retroflexion, and dextro- and sinistro-flexion. Finally, it may be twisted 
upon itself, producing a torsion. 

253. Ascent is the least frequent form of displacement. Those 
conditions which increase the weight of the organ, naturally, by force of 
gravity, depress it. It is only when the uterus has attained a size so great 
that it is no longer accommodated within the pelvis that ascent occurs. 
This is recognized as a physiologic ascent in pregnancy, and occurs after 
the fourth month, when the uterus becomes so large that it can no longer 
be retained within the pelvis, and rests upon the brim. A similar state 
develops when fibroid growths are situated in the organ and become large. 
(Fig. 361 .) The uterus is drawn or pushed up by growths which may have 



422 



GYNECOLOGY. 



developed in the pelvis and become adherent to it. As they increase in 
size and rise out of the pelvis, they drag or push the uterus up with them. 
Ovarian tumors, extra-uterine pregnancy, extensive pelvic exudation, 
hematocele, and retro-uterine growths may bring about an elevation of the 
uterus. 

Diagnosis. Elevation of the uterus may be determined by digital 
examination. The cervix is absent from its usual position in the vagina. 
Frequently it is so elevated as to be reached with difficulty behind or even 
above the symphysis. Often a growth or mass fills the pelvis, over which 
the cervix cannot be reached. Sometimes greater difficulty is experienced 
in determining the condition which has caused the displacement, and this 




Fig. 362. — Uterovaginal Prolapse. 



is more important than the treatment, which is entirely dependent upon the 
cause producing the displacement. 

254. Descent, or Prolapsus, of the uterus varies in degree. By this 
term is understood a downward displacement of the organ, which is gener- 
ally associated with retroversion, so that often retroversion is considered 
as the first degree of prolapsus. The uterus is situated at a lower level 
with the OS directed in the axis of the vagina. The second degree of 
prolapsus is when a portion of the organ protrudes through the vulvar 
orifice, and the third degree when the entire uterus is outside of the vulva. 
This term includes a partial or complete prolapsus or inversion of the 
vagina. Prolapsus also may be complete and incomplete, according to the 
situation of the uterus. When the organ still is situated within the vagina 
or only a portion protrudes from the vulva, prolapsus is incomplete; 



DISPLACEMENTS OF THE PELVIC ORGANS. 423 




Fig. 363. — ^\^agi no-uterine Prolapsus. 




Fig. 364. — ^Vagino-uterine Prolapsus with Hypertrophic Elongation of the Cervix. 



424 



GYNECOLOGY. 



but when the entire uterus is external to the vulva, prolapsus is complete. 
The term procidentia is also applied to prolapsus, but only when the entire 
uterus is external. Prolapsus is further divided into three varieties, 
according to the relation of the uterus to the vagina. 

(i) It is called uterovaginal prolapsus (Fig. 362) when the uterus is ex- 
truded through the vagina with only partial inversion of the latter; (2) 
vagino-uterine prolapsus when the prolapsus begins in the vaginal walls, 
and more or less extensive protrusion of the vagina precedes the uterine 
prolapse. (Figs. 363 and 366.) The prolapsus of the uterus may be 
incomplete while the vagina is inverted, and a hypertrophic elongation of 
the cervix exists. (Figs. 364 and 365.) (3) Pseudo-prolapsus is a con- 




FiG. 365. — Uterus Detached, Showing Hypertrophic Elongation of the Cervix. 



dition in which a large portion of the cervix projects into or through the 
vulva, while the fundus retains its normal position and the vaginal walls 
are unaffected (Figs. 367 and 368). In the latter case the hypertrophic 
elongation takes place in the vaginal portion of the cervix. 

Etiology. The causes of prolapsus may be classified under three 
heads: first, decreased support; second, increased weight; third, increased 
intra-abdominal pressure. These conditions can exert their influence 
separately, but usually they act in conjunction. Decreased support is 
characteristic of individuals who have given birth to one or more children, 
and in whom the pelvic structures have been injured during the process of 
parturition. Laceration of the perineum or removal of the support of the 
posterior segment of the pelvic floor permits a protrusion of the anterior 
wall of the vagina and the bladder during the distention of the latter. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



42: 



This protrusion of the anterior segment of the pelvic floor, because of the 
close attachment of the bladder to the cervix, drags upon the latter, and, 
unless the uterus is fixed by firm ligaments or inflammatory adhesions, 
the entire organ is gradually brought into the axis of the vagina, with 
its fundus thrown backward, and the intra-abdominal pressure will sub- 
sequently be directed upon it or its anterior surface. The decreased 
support to the posterior w^all of the vagina removes antagonistic action of 
the sphincter and straining at stool, coughing, or lifting, causes protrusion 
of this segment with the rectum, and the cervix is drawn upon by both the 
anterior and posterior vaginal walls. Decreased support may exist in 
women who have not given birth to children, where, owing to want of 




Fig. 366. — ^\"ulvar Appearance of A'agino-uterine Prolapsus. 

normal muscular development, to ill health, or to too straight a sacrum, 
the support is lessened and the muscles of the pelvic floor are greatly 
relaxed. If, in such cases, intra-abdominal pressure is increased, extensive 
displacement results. Prolapsus may thus be produced in the unmarried. 
In complete laceration which extends through the sphincter, prolapsus is 
less likely to occur. In marked relaxation and want of pelvic support, 
which have resulted from lesions of parturition, the tendency to prolapse is 
increased by enlargement of the uterus or by failure to complete the process 
of involution. The uterus remains heavy, so that these two forces, 
decreased support and increased weight, acting in conjunction, lead to 
descent. It is true, we may have prolapsus when the uterus is small. 



426 



GYNECOLOGY. 




Fig. 367. — ^Pseudoprolapsus. Cervix Within the Vagina. 




Fig. 368. — Pseudoprolapsus. Cervix Protruding from Vulva. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



427 



When, subsequent to the climacteric, the patient loses flesh, the absorption 
of the fatty cushion decreases the amount of support, and, with enfeebled 
muscular action, permits a small uterus to be driven through the pelvis. 
This is a cause of prolapsus in the aged. Increased intra-abdominal 
pressure may arise from want of proper hygiene in clothing. Tight 
corsets and heavy skirts fastened about the waist afford insufficient room 
in the abdomen for the viscera, which are driven downward into the pelvis. 
Neglect to evacuate the bowels and the bladder increases the tendency to 
displacements. Prolapsus is favored by straining at stool, by lifting and 




Fig. 369. — Anterior and Posterior Colpocele. 

carrying heavy weights. Not infrequently a patient will give a history of 
having lifted a weight or of violent straining, after which a protrusion was 
noticed at the vulvar orifice. In such cases the condition has existed for 
some time, and generally has been aggravated only at the time of extra 
effort. The presence of growths within the abdominal cavity — fibroid 
tumors, ovarian cysts — which press upon the uterus may force it down. 
In relaxation of the pelvic floor it is not unusual to observe a prolapsus of 
the uterus, which has been produced by the increased intra-abdominal 
pressure incident to the presence of a new-growth. 



428 



GYNECOLOGY. 



Symptoms. In the early stages of prolapsus of the uterus there are no 
characteristic symptoms. The patient complains of a sensation of weight, 
pressure, discomfort in the bladder, a feeling of burning in the rectum, and 
dragging sensation while walking or standing — all of which may be asso- 
ciated with other conditions. As the prolapsus progresses, the patient 
will notice a protrusion from the vulvar orifice, which is increased by 
straining and lifting. As this protrusion increases, the close association 




Fig. 370.— Cystocele. 

of the bladder with the cervical wall causes the uterus to be dragged down. 
The bladder, with exceedingly rare exceptions, accompanies the displace- 
ment. Occasionally, however, the peritoneal fold may be driven down 
between the bladder and the uterus, and a prolapsus thus occur without 
the bladder being associated with it. With the continuation of the pro- 
lapse the anterior wall becomes more and more everted, and, not infre- 
quently, forms a considerable-sized tumor, which projects anteriorly, is 
increased by straining, and forms a tumor with a smooth, globular surface. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



429 



This protrusion of the anterior vaginal wail and bladder is known as a 
cystocele. (Fig. 369.) The posterior wall of the vagina may be likewise 
protruded, though less frequently than the anterior. In cases of inversion 
of the vagina the posterior wall is generally associated, although even then 
not to the same degree as the anterior. The posterior protrusion is known 
as a rectocele. The uterus is separated from the rectum by a prolongation 
of the peritoneum which extends below the rectum on the posterior wall 
of the vagina. In the inversion of the posterior wall of the vagina to form 
a rectocele, the intestine may or may not be associated with it. Occasion- 




FiG. 371. — Prolapsus with both Rectocele and Cystocele. 



ally the want of support of the anterior rectal wall permits it to be pushed 
downward, and form a diverticulum considerably below the anus, which 
renders the evacuation of the bowel contents difficult, at times impossible, 
unless the protrusion is pushed up with the hand, when the scybalous 
masses situated in the pouch can be extruded. In complete vaginal 
prolapsus with the formation of an extensive cystocele a portion of the 
bladder is situated below the level of the internal orifice of the urethra, and 
as this protrusion increases, the bladder is incompletely evacuated. The 
retained urine with mucus in this reservoir undergoes decomposition, form- 



430 



GYNECOLOGY. 



ing an ammoniacal urine, which irritates the mucous membrane of the 
bladder and produces a cystitis. In this diverticulum, with a plug of mucus 
as a nucleus, a calculus of considerable size can form; indeed, one weighing 
an ounce has been found in such a sulcus. With the protrusion the distress 
of the patient is greatly increased, because of the bladder irritation and the 
friction of the protruding tumor against the clothing and limbs of the patient. 
The urethra, instead of passing upward and backward as in the normal 
situation, passes backward — even downward. The protruded vagina in a 
complete prolapsus may form a large tumor extending half-way to the knees, 
in which tumor is situated a portion of the bladder, the uterus, ovaries, 
tubes, and prolapsed intestines — an extensive hernia. (Fig. 372.) The 
mucous membrane of the vagina loses its moistened, reddish appearance, 
and instead becomes pale, thickened, and covered with flakes of epithelium,.. 




Fig. 372. — Irreducible Prolapsus. The Tumor Contained Uterus and a Large Pyosalpinx. 

Ulceration of Cervix. 

and resembles the appearance of the skin. Bathed with urine and fecal' 
matter, irritated by the clothing and by friction against the limbs, and 
congested from the decubitus, ulceration is produced upon the external os 
and upon the sides of the tumor, which, at times, causes extensive loss of 
structure and adds greatly to the discomfort of the patient. In the early 
stage of the displacement the menses are increased, possibly irregular, 
and occur at shorter intervals. Leukorrheal discharge is present, often 
profuse, as a result of the congestion. As the prolapsus becomes more ex- 
tensive and approaches nearer to complete prolapsus, menstruation is 
likely to be decreased and the leukorrheal discharge disappears. The 
displacement does not necessarily interfere with conception, as pregnancy 
has often occurred with complete prolapsus; but in the later stages the 
patient is more likely to be sterile. 

Diagnosis. The patient considers every protrusion from the vulva 



DISPLACEMENTS OF THE PELVIC ORGASN 



431 



to be a prolapsus or falling of the womb. The diagnosis would seem 
self-evident, but it must be conceded that not every such protrusion 
is necessarily a prolapse of the uterus, and it is important to determine 
the degree, the form of prolapsus, and the structures involved. This 
knowledge is obtained by inspection, while the patient is directed to increase 
the displacement by straining and bearing down. It is further confirmed 
by touch. A cystocele is a protrusion from the anterior part of the vulva, 
continuous with the urethra and anterior wall. It is the most frequent 
protrusion from the vulva, and may be accompanied in part or wholly by 




Fig. 373. — Prolapsus without Protrusion of Vaginal Walls. 

the uterus. In cystocele the finger enters the vagina behind the protruding 
mass, which generally can be replaced with ease. The cervix accompanying 
it will be situated at its posterior surface. A protrusion of the posterior 
vaginal wall is recognized by its continuity with the perineum, and the 
finger enters the vagina in front of it. Considerable protrusion of the 
vaginal walls may occur without much, if any, displacement of the uterus. 
The degree of displacement of the anterior and posterior vaginal walls 
is recognized by the introduction of the finger around the uterus. Thus, 
the cervix may protrude from the vulva without there being any shorten- 



432 



GYNECOLOGY. 



ing of the posterior, and but slight shortening of the anterior vaginal 
wall. With inversion, or complete prolapse of the vagina (Fig. 371), 
the summit of the protrusion is occupied by the cervix, which may ap- 
pear as a normal-sized opening, or external os; or, when laceration of the 
cervix has occurred, the lips may be widely everted, and show an irritated 
cervical mucous membrane. When prolapsus is complete, the uterus 
is situated in the tumor, external to the vulva, generally in the position of 
retroversion or retroflexion; it is rarely anteflexed. The uterovaginal 
form of prolapsus is determined from the vagino-uterine variety by the 
lessened involvement or association of the vagina with the protrusion. 
In the uterovaginal form (Fig. 373) the uterus is driven through the 




/>"/.» 



Fig. 374. — Determination of the Position of the Uterus by Bimanual Palpation. 

vagina, drags the upper part with it, and finally results in partial inversion 
of the canal. When prolapsus is complete, the uterus is likely to be small 
and its cavity short. In the vagino-uterine variety the prolapse begins 
at the lower segment of the vagina by a rolling outward of the anterior 
and posterior walls. The thickened and everted vaginal walls drag upon 
the cervix, and lead to displacement of the uterus; or, where the fundus 
is fixed by the condition of its ligaments or by inflammatory disorders, the 
cervix is drawn out, and causes a very marked elongation of the uterus. 
This condition is determined by placing the fingers of one hand in front 
of, and those of the other hand behind, the protruding mass. This also 
reveals the situation of the fundus of the uterus. (Fig. 374.) If the 
protruding tumor is grasped between the thumb and fingers of one hand 



DISPLACEMENTS OF THE PELVIC ORGANS. 



433 



the fingers will distinguish the uterus outside the vulva, or the cord-like 
cervix protruding into the vagina, when hypertrophic elongation of the 
cervix exists. (Fig. 375.) The situation of the fundus can be recognized 
still further by the introduction of the finger into the rectum. By drag- 
ging upon the cervix with a tenaculum while passing the finger into the 
rectum the attenuation of the neck is determined, and the situation of the 
fundus is recognized. (Fig. 376.) In pseudoprolapsus the fundus is but 
little displaced from its normal situation. There is a protruding mass 
from the vulvar orifice, and the introduction of the finger into the vagina 
shows that the vaginal walls are not displaced. Elongation has taken place 
in that portion of the cervix which is situated below the vaginal attach- 
ments. It generally results from enlargement and increased weight of 




Fig. 375. — Recognition of Uterus with Thumb and Fingers of One Hand. 



the cervix. The anterior segment of the vagina is attached to the cervix 
at a lower level than the posterior. Occasionally, we find a protrusion of 
the anterior wall of the vagina, with the cervix at its posterior surface, 
while the introduction of the finger into the vagina shows that the posterior 
vaginal wall is not displaced. (Fig. 377.) In other words, the elonga- 
tion has occurred in that portion of the cervix situated between the at- 
tachment of the anterior and the posterior vaginal walls. 

In considering the differential diagnosis we must concede the possibil- 
ity of the protrusion having arisen from a cyst in the anterior wall of the 
vagina, a hernial protrusion through the posterior fornix, a fibroid polypus, 
and an inversion of the uterus, associated with inversion of the vagina. 
Cyst of the vagina is recognized by bimanual palpation. A catheter 
or sound introduced into the bladder, and a finger into the vagina, will 
28 



434 GYNECOLOGY. 

reveal an abnormal thickness of the anterior wall, and readily disclose 
the character of the condition. The bimanual examination can reveal a 
fibroid polypus protruding from the orifice of the cervix by a more or 
less distinct pedicle. Traction upon the tumor and the introduction of a 
finger into the rectum will disclose the position of the uterus. Displace- 
ment of the rectum is not generally associated with prolapsus of the 
vaginal walls, and, when it exists, is less intimately connected. Inver- 
sion of the uterus is recognized by a protruding tumor, which does not 
present an external os, is more sensitive and under careful examination 
shows the orifices of the Fallopian tubes. It is a globular, well-shaped 







Fig. 376. — Diagnosis of Position of the Uterine Body by Rectal Touch. 

tumor, which can lead to an inversion of the vagina in which the 
relation of the cervix to the tumor and the vagina is readily determined. 

Enterocele, or hernia through the posterior fornix of the vagina, is a 
rare condition, although I have seen two such cases in which the hernia 
extended to the vulva. (Fig. 378.) The tumor is generally more elastic 
and is greatly distended. The absence of the uterus, in association with 
it, is recognized. On reduction of the hernia the opening into the poste- 
rior fornix, through which it had passed, is readily recognized. 

Prognosis. The results of treatment must depend upon the stage 
of development, the existing complications, and the manner of life the 
patient is required to live. The earlier the displacement comes under 



DISPLACEMENTS OF THE PELVIC UTERUS. 



435 



observation, the less radical will be the means required to maintain the 
organ in its replaced position. When both uterus and vagina are pro- 




FiG. 377. — Hypertrophic Elongation of the Cervix. Anterior Vagina Everted, while Pos- 
terior Retains Its Normal Position. 




Fig. 378. — Enterocele through the Posterior Vaginal Fornix. 

lapsed, changes have taken place which are beyond our skill to restore 
to the previous condition. While much can be done for the comfort 



436 



GYNECOLOGY. 



of the patient in all cases, in some, however, it may be necessary to 
sacrifice the uterus and part of the vagina. The irritation to which the 
vagina is subjected will sometimes lead to the development of an epithe- 
lioma. (Fig. 379.) Not infrequently we will find gravity sores and exten- 
sive ulcerations as a result of friction and interference with the circulation. 
The restoration and maintenance of the pelvic organs in their proper place 
will depend upon the complications which may be associated with the 
displacements. The most frequent complication is the sequel of inflam- 
matory changes, in which the displaced organs are more or less fixed 
by extensive exudation and adhesions. In procidentia the protruding 
sac or hernia, in addition to the uterus and part of the bladder, is likely 
to contain the ovaries and tubes, and even a large portion of the large 
and small intestines. Inflammatory changes in such a condition may 
lead to an irreducible hernia, which must necessarily add very much to 




Fig. 379. — ^Vagino-uterine Prolapse Complicated by Proliferating Epithelioma. 



the distress and discomfort of the patient. Such a patient can neither 
sit nor stand with comfort. In one patient (Fig. 372) a large protrud- 
ing sac contained the uterus, ovaries and tubes. The latter having be- 
come infected resulted in the formation of a considerable abscess. For- 
tunately, the condition was irreducible. Otherwise the reduction of such 
a mass into the abdominal cavity might readily have resulted in rupture 
of the tube and general infection of the peritoneum. In one instance I 
was obliged to remove the uterus because of a partial necrosis of its struc- 
ture. Ordinarily, hysterectomy would not be the operation of election, 
as removal of the uterus leaves an open space, difficult to close thoroughly, 
and favors the subsequent development of a vaginal hernia, which is 
difficult to remedy. With the retention of the uterus and its proper an- 
chorage in the pelvis it serves as a plug and obstruction to the redevelop- 
ment of a hernia. It is self-evident that the patient who is enabled to live 
a luxurious life need not be subjected to the same treatment as the woman 
who must maintain herself, and, possibly, the members of her family, 
by laborious industry. The former, by rest and proper hygiene, may be 



DISPLACEMENTS OF THE PELVIC ORGANS. 437 

able to prevent the development of the prolapsus, consequently an op- 
erative procedure may be delayed or mechanical means employed to 
overcome the condition, while the woman who must earn her living 
at the washtub or by continuous maintenance of the upright position 
will require operative interference in order to prevent a more extensive 
displacement. 

Treatment. The treatment of prolapsus uteri must necessarily de- 
pend upon the extent of the displacement, the involvement of the vagina, 
the distention of the vaginal orifice, and the age and physical condition 
of the patient. The most important treatment is prophylaxis. This 
consists in the careful management of the woman during labor and the 
puerperium; the early repair of lacerations of the cervix and perineum; 
the examination of the patient subsequent to her delivery to determine 
the condition and situation of the uterus. The advent of inflammatory 
conditions should be followed by judicious treatment, such as the employ- 
ment of hot vaginal douches; cold applications over the abdomen; rest 
in bed; depletion of the uterus; and, where endometritis exists, the use 
of the curet. A heavy uterus should be sustained by tampons or a pes- 
sary, until the process of involution has been completed. The treatment 
of prolapsus may be hygienic, mechanical, or operative. 

Hygienic treatment comprises the wearing of proper clothing. A 
woman with a tendency to prolapsus of the uterus should not have her 
abdomen constricted. The increase of the intra-abdominal pressure 
necessarily aggravates the displacement; consequently, the clothing 
should be loose. Skirts should be suspended from the shoulders rather 
than from the waist; the bowels should be kept regular and all straining 
at stool avoided; lifting and carrying heavy weights should not be under- 
taken; the patient should frequently assume the knee-chest position, 
and, while in this attitude, separate the vulva in order that the air may 
enter and magnify the influence of gravity in restoring the displaced 
organs. This position should be particularly assumed for several minutes 
as a last act before retiring, and patients should assume the lateral or 
prone position rather than the recumbent. 

Mechanical treatment of prolapsus consists : i , in the reduction of the 
displaced uterus or its return to a normal position; 2, in the employment 
of means to insure that this position will be maintained. The first step, 
then, in treatment is to replace the displaced organs. Ordinarily this 
is not difficult, as the increased size of the vaginal canal readily permits 
the organ to be carried upward to its proper place. Where the displace- 
ment, however, is complicated by inflammation with extensive exudation 
into the pelvis, it may result in matting together the uterus, ovaries, and 
tubes with knuckles of intestine and portions of omentum. Such a con- 
dition will render the restoration of the organs exceedingly difficult, if 
not impossible, without resort to operative interference. Sometimes the 
displaced uterus, from passive congestion or edema, will become so large 
and engorged that it cannot be replaced through the pelvic canal. This 
is particularly apt to occur in those cases in which the prolapse is complete 
and the uterus and vagina have been subjected to friction against the 



43^ GYNECOLOGY. 

clothing, causing the formation of gravity sores, and sweUing to such an 
extent that the mass is rendered too large to be returned through the pelvis. 
Such a tumor may sometimes be reduced in size by the application of an 
elastic bandage, or by keeping the patient perfectly quiet in bed, with the 
pelvis somewhat elevated, and cold applications applied to the swollen 
structures. Cloths wet with lead-water and laudanum and covered with 
oiled silk, over which an ice-bag is applied, will frequently be effective 
in relieving the engorgement, and after a few days' treatment will result 
in such a decrease in size as to permit the parts to be reduced. The 
organ can be replaced with much greater ease by placing the patient in 
the genupectoral position. While the patient is in this position the tumor 
can be drawn down, compressed with the fingers, and gradually pushed 
up to its normal site within the pelvis. A mass too large to permit of 
its replacement with the patient in the dorsal position can generally 
be returned while in the knee-chest posture. When the uterus is fixed 
by inflammatory exudate, the patient should be put to bed, the parts sub- 
jected to pelvic massage, and in the intervals the uterus supported as 
high as possible by tampons of cotton and gauze, or, probably still better, 
lamb's wool saturated with medicinal agents, in which glycerin shall 
form an essential part. This treatment should be alternated with hot 
vaginal douches. Inflammatory adhesions may also be overcome by the 
employment of continuous weight or pressure. This is rather difficult to 
apply within the pelvis, because of its being the most dependent portion 
of the trunk. The patient can be placed on her side, with the pelvis some- 
what elevated. Pressure is then obtained by introducing into the vagina 
a small rubber bag containing mercury. The continued pressure thus 
directed upon the surface will promote the absorption of the exudation, 
and, by change of position the uterus can be worked gradually free from 
the exudate. Thus, tampons, douches, massage and pressure should be 
employed until the uterus becomes freely movable and its reposition is 
accomplished. This, of course, is desirable as a preliminary to the em- 
ployment of such a mechanical support as the pessary. In cases of pro- 
lapsus the pessary acts by so distending the upper part of the vagina that 
the levator ani and the muscles of the pelvic floor form a support for the 
instrument and thus prevent displacement. Consequently it is necessary 
that the pessary shall be of sufficient size to accomplish this distention. 
(Sec. 112.) 

In the use of many of the pessaries, however, it is absolutely necessary 
that the pelvic floor shall afford a point of resistance to the intra-abdominal 
pressure. When the pelvic floor has been lost, or where the prolapsus is 
of the vagino-uterine variety, the pessary, having no point of resistance,, 
is at once extruded when the patient makes a straining effort, or even upon 
standing.' In such cases a pessary may be employed with an external 
support.' Such an instrument, however, is exceedingly uncomfortable; 
the stem, and straps are irritating to the delicate external surfaces. The 
cup may 'Cause ulceration and abrasion of the cervix and vagina. The 
employment of a pessary in prolapsus can be only palliative. It has no 
power to restore function to the part. A patient came under my observa- 



DISPLACEMENTS OF THE PELVIC ORGANS. 439 

tion who had worn a pessary for twenty-six years. This had produced 
such marked abrasion and irritation of the vagina that granulations had 
sprung up which enveloped the greater part of the instrument with new 
tissue. The pessary was cut with bone-pliers, and each half removed 
separately, leaving undisturbed the mass of cicatricial tissue by which 
the uterus was subsequently supported. I have seen, in several instances, 
the bulb or glass-ball pessary worn for a long period of time, until it 
resulted in cicatricial changes in the vagina, which formed the support for 
the atrophied uterus. The maintenance of the uterus by the establish- 
ment of cicatricial tissue has been attempted by the injection of quinin 
and other irritating materials into the broad ligaments. This was done 
in order to establish a cellular inflammation, which should cause such con- 
traction of the connective tissue as to retain the uterus in position. Such 
a plan of treatment, however, is attended with too much danger to justify 
its employment. 

Operative treatment affords the only means which can be considered 
radical, or as giving hope for the restoration of the structures and their 
maintenance in normal position. In the employment of such measures 
I wish to direct attention to the three causes which have been assigned 
for the development of. prolapsus. These are, increased weight of the 
uterus, decreased pelvic support, and increased intra-abdominal pressure. 
The malposed uterus is rendered heavy by a condition of subinvolution 
or chronic inflammation,, which has in part resulted from obstruction to 
its circulation. Not infrequently will we find that the cervix has under- 
gone hypertrophic elongation, and the vaginal walls are dragging upon 
this elongated portion of the organ. The first step, then, in the restora- 
tive process, should be the amputation of the cervix. This decreases 
the size of the uterus, not only by the amount of the cervix removed, but 
by the favorable metabolism thus engendered. The amputation may be 
free or the double-flap or single-flap method can be employed (Sec. 208), 
according to the particular pathologic condition present. In performing 
this operation we would suggest that the cervix be sutured with chromic 
catgut, as such sutures can be allowed to remain; moreover, the stretch- 
ing of the newly united surfaces consequent upon the removal of sutures 
is thus avoided. The second indication is met by narrowing the vaginal 
canal and reconstructing the pelvic floor. Early in the history of gynecol- 
ogy various operations were devised to secure this object. Sims did a 
triangular denudation upon the anterior wall, the surfaces of which were 
united and the canal thus reconstructed. The method of freshening 
the surface will largely depend upon the character and form of the pror 
lapsus. Furthermore, the maintenance of the uterus in position by nar- 
rowing the vagina will be especially applicable to the correction of the 
cystocele. a 

Cystocele is frequently a sagging of the anterior segment of the pelvic 
floor alone or in conjunction with the uterus and posterior segment, 
and operative procedure to maintain it in place must take into considera- 
tion this situation of the bladder. The portion of the bladder displaced 
often will be found to be below the level of the internal orifice of the urethra 



440 



GYNECOLOGY. 



when a portion of the urine remains, undergoes ammoniacal fermentation 
and decomposition, and leads to the deposition of calculi which further 
aggravate and add to the distress of the patient. 

Correction of the condition demands not only the contraction of the 
anterior vaginal wall, but the elevation and maintenance of the bladder 
at a higher level. Where the displacement of the bladder is not marked, 
an elliptical section of the relaxed vaginal wall may be removed and the 
edges sutured transversely (Fig. 380.) A relaxed condition of the 
bladder may be overcome by separating it from the cervix by blunt dis- 





■i 


V 








MJ . 


^^Hi~ 








'^^^ 1 


■K 






1 


§i 


m 




I 




1 


1 


^^K^^Sk '9 




^ 


H 


1 


1 ^ 


/ 



Fig. 380. — Anterior Colporrhaphy. Anterior Vaginal Wall Removed. 



section and, as suggested by Goffe, suturing the relaxed portion high up 
on the anterior surface of the cervix. The operation is completed by 
transverse sutures of the anterior vaginal wall a portion of which may have 
been excised from each side. The suturing as completed is seen in Fig. 
381. The folding of the bladder decreases its pressure against the 
reconstructed walls. The closure of the vaginal wall should begin near 
the cervix and the suturing extend outward, the cervix being pushed up- 
ward with the tying of each suture. This procedure secures a strong an- 
terior segment of the pelvic floor. The line of suturing should be vertical 



DISPLACEMENTS OF THE PELVIC ORGANS. 



441 



and the sutures of chromic catgut. The aim of the operator should be to 
make a long anterior wall, to hold the cervix backward, and, consequently 
tilt the fundus uteri forward. In greatly relaxed vaginal walls the 
excision may be made circular, and the wound closed with the Stolz's 
suture. (Fig. 382.) This, however, contracts the vagina in every direc- 
tion and, therefore, is less favorable in the majority of cases than the 
method of anterior colporrhaphy already described. The ordinary 
method of performing the operation, known as anterior colporrhaphy, 
consists in making a denudation which does not penetrate the entire va- 



/ i 




Fig. 381.— Wound Closed. 



ginal wall. When sutured, such a denudation forms a wall of connective 
tissue, which is not so durable as the method we have described. Wat- 
kins controls this condition very effectively by the following procedure: 
The anterior vaginal wall is separated from the cervix by a semilunar 
incision, and is incised in the median line from the cervix to within half- 
an-inch of the external meatus of the urethra. The bladder is separated 
from the cervix by the finger covered with gauze. Where this is not 
accomplished readily, it often may be done more easily from the sides 
where the attachment is not so firm. The peritoneum when reached is 



442 



GYNECOLOGY. 



opened and the fundus turned down with the aid of bullet forceps. The 
peritoneum is stitched to its posterior surface and two sutures are inserted 
through the vaginal walls and the posterior surface of the fundus so as to 
carry the fundus under the bladder, care being exercised that it does not 
make pressure against the inner end of the urethra and thus obstruct the 
flow of urine. (Fig. 383.) The superfluous material in the vaginal walls 
is cut away and the vagina united over the uterus. (Fig. 384.) Gener- 




FiG. 382. — Stolz's l*urse-string Suture. 



ally the operation upon the anterior vaginal wall should be supplemented 
by one upon the posterior. This may be slight or extensive, according 
to the amount of relaxation. The restoration of the posterior segment 
may be accomplished by performing the operation known as the modi- 
fied Garrigues-Hegar, or the operation designed by Emmet. 

While any one of a number of procedures may be followed for the 
restoration of the pelvic floor, the one described (Sec. 225) for lacera- 
tion of the pelvic floor will prove serviceable in the majority of cases. 
Its great value is in the restoration of the forces antagonistic to the 
sphincter ani and the support given to the rectal wall. Decrease in 



DISPLACEMENTS OF THE PELVIC ORGANS. 



443 




Fig. 383. — Watkin's Operation for Cystocele. Sutures inserted for Carr3ang the Fundus 

Under the Bladder. 




Sac. 

Fig, 3S4. — Situation of the Uterus in Completion of the Watkin's Operation. 



444 GYNECOLOGY. 

the size of the uterus, and restoration of the pelvic floor, will, in many 
cases, prove effective in maintaining the uterus in its proper position. 
In others, however, where the uterus is large, fails to maintain its 
proper axis, and drops backward, the intra-abdominal pressure will tend 
to drive it through the newly united canal and reestabhsh the hernia. It 
is consequently important that the uterus should be anchored within the 
abdomen, to prevent such an occurrence. This anchoring of the uterus 
may be accomplished by the operation known as ventrosuspension, or ven- 
trofixation. The same purpose can be effected by one of the operative 
procedures which utilize the round ligaments, as in the Alexander, the 
Gilliam-Ferguson, the Ries, or other modifications, which will be described 
later. Of course, the aim of the operative procedure is to maintain the 
fundus of the uterus forward. This can be accomplished by vagino- 
uterine fixation or by shortening the round ligaments through the vagina. 
Such operations can be done in association with those upon the anterior 
wall of the vagina, as in the procedure we have already described. When 
the bladder is pushed away from the cervix, it is very easy to enter the 
peritoneal cavity through an anterior colpotomy and employ the op- 
portunity thus afforded to break up adhesions, to treat ovarian and tubal 
disease, and to restore the uterus to its normal position. The incison 
through the posterior vaginal fornix is also used to shorten the uterosacral 
ligaments. It will readily be understood that if the cervix is carried up- 
ward and backward, the fundus will necessarily fall forward. The con- 
traction of the uterosacral ligaments, or the tissue in which they are usually 
situated, is of special value in marked prolapsus, for if ventrosuspension 
or fixation is done, or one of the operations upon the round ligaments 
alone, we would have the uterus hanging and dragging upon its anchorage. 
Shortening the uterosacral ligaments, however, lifts up the cervix and, 
consequently, throws forward the fundus, thus making the uterus serve 
as a plug to obstruct the egress through the pelvis. Where the utero-sacral 
ligaments are shortened as a part of the general procedure, they should 
be exposed before the sutures are tied in the operation upon the anterior 
vaginal wall. Bovee advises that the ligaments be exposed by a vertical 
incision from the posterior surface back toward the rectum, which shall 
extend to, but not through, the peritoneum. The latter is pushed off on 
either side until the thickening indicating the position of the ligament 
can be determined. Each ligament should be seized about its middle 
with a hemostat and drawn downward, while traction upon the cervix 
is discontinued. Each loop should be transfixed by a suture which is 
tied and the end of the doubled ligament secured just behind the cervix, 
near the normal attachment of the ligament. This course applied to both 
ligaments results in holding the cervix at a higher level and in many cases 
may obviate the necessity for opening the abdomen. In anterior colpor- 
rhaphy the sutures for closing the wound should have been introduced and 
secured by hemostats before the incision to expose the uterosacral liga- 
ments, and after the latter are secured, as indicated above, the former 
should be tied. By this course no traction is made upon sutures after 
they have been secured. These measures may be supplemented further 



DISPLACEMENTS OF THE PELVIC ORGANS. 



445 



by the retraction of the posterior vaginal wall or pelvic floor. When the 
ligaments have been secured, the vaginal incision for their exposure 
should be united by continuous catgut suture, leaving a vent through 
which gauze drainage can be employed. Freund advised in aged women, 
in whom the prolapsus was marked and the condition of the patient un- 
favorable for a radical operation, that silver wire sutures should be passed 
so as to form successive rings beneath the uterus. The introduction of 
the sutures should begin immediately beneath the cervix, so as to push up 




Fig.- 3S5. — Fii-st Stage of Dudley's Bilateral Denudation of the Vaginal Walls for Prolapsus. 

and maintain the organ at a higher level. He directed that they be drawn 
moderately tight and fixed by twisting; the ends are then cut off and 
pushed into the vesicovaginal septum. The silver wire thus secured forms 
successive bands or hoops around the restored vagina, which it was 
thought would maintain the uterus in place. My own experience, how- 
ever, is that upon very slight exertion the entire condition is reestablished. 
Moreover, the silver wire sutures are likely to cause irritation or possibly 
the formation of abscess, which will ultimately require their removal. 



446 



GYNECOLOGY. 



Attempts have been made to maintain the uterus within the pelvis by in- 
flammatory changes in the broad ligaments. Injections of quinin hy- 
podermatically have been employed for this purpose, but such procedures 
must be futile, inasmuch as they meet but a part of the required indica- 
tions. Wiggins endeavored to accomplish the same by an intraperitoneal 
purse-string suture in each broad ligament. In prolapsus of large uteri, 
complicated by inflammation of the tubes and ovaries, with bands of 
adhesion fixing omentum or coils of intestine to the uterus and bladder 
and with the subsequent cicatricial changes, the preferable plan of pro- 
cedure, in my judgment, is the partial or complete removal of the organ. 
Even so radical a procedure should be supplemented by a plastic opera- 
tion upon the vagina, in order to narrow the canal and afford better sup- 




r^H' 



Fig. 386. — Dudley's Operation, Showing Denudation upon One Side of the Vagina. 

port to the abdominal viscera. Such patients, even though old, bear 
operation fairly well. Where the condition of the uterus will permit of 
its retention, the organ should not be sacrificed. We have already cited 
reasons why hysterectomy should not be the operation of election. In 
hypertrophic elongation of the cervix it may be difiicult, by simple ampu- 
tation of the cervix and fixation of the uterus, to elongate the vagina suffi- 
ciently to prevent recurrence of the hernia. In such cases, especially 
where the woman has passed the climacteric, supravaginal amputation 
of the fundus uteri, through an abdominal incision, followed by suturing 
the stump, covered with peritoneum, to the broad ligaments upon each 
side, as advocated by Baldy, wfll be effective, or when the vagina is very 
much relaxed, we may sew the stump of the cervix directly to the abdom- 



DISPLACEMENTS OF THE PELVIC ORGANS. 



447 



inal parietes, as advocated by Noble. E. C. Dudley asserts that the part 
of the vagina most resistant to displacement is its lateral surface, and 
that, instead of narrowing the vagina on the anterior and posterior walls, 
the preferable plan of procedure would be to denude an elliptical surface 
upon either lateral fornix, with the long diameter anteroposterior. The 
edges of newly made surfaces are apposed and secured with sutures 
through the long diameter. From this a lateral denudation is made upon 
either side, in which the sutures are introduced from behind forward and 
from above downward, in such a way as to lift up the anterior wall of the 
vagina. (Figs. 385 and 386.) Even in marked cases of prolapsus sutures 
may be introduced so as to serve in some degree to anchor the lateral 
surfaces of the vagina. 

255. Urethrocele. The urethra, in extensive cystocele, is generally 
more or less involved. As has already been recognized, the intimate 
connection of the bladder and urethra with the anterior vaginal wall 




Fig. 387. — Urethrocele. 

necessitated their association in any prolapsus of the latter structure. 
When a segment of the bladder is situated below the internal orifice of 
the urethra, the upper part of the urethra, as a consequence, becomes pro- 
lapsed. The lower segment of the urethra, however, generally retains its 
normal situation. Occasionally we may have a protrusion from the central 
portion of the urethra, which forms a sac-like projection (Fig. 387) at the 
lower portion of the anterior wall of the vagina. This latter condition 
is independent of any uterine or vaginal displacement. This projection, 
on the introduction of a catheter, is found to be a part of the urethra. 
It is at times so large as to form a kind of diverticulum, over which the 
urine flows, without entering it, or enters it only to a limited extent. 
Pressure over the urethrocele causes a discharge of profuse purulent 
material, although pus has not previously been found in the urine. The 
treatment consists in dissecting out the sac, a catheter having been 
previously introduced as a guide. The opening in the urethra is closed 



44^ GYNECOLOGY. 

while the catheter is in place. The vaginal wall is then sutured over 
this wound, and the urine is subsequently evacuated through a perma- 
nent catheter for two or three days. 

256. Dislocation of the uterus is a displacement in which there is but 
slight change in its axis. These dislocations may be forward, backward, 
or lateral. The organ is more or less fixed in the abnormal position by 
inflammatory changes, frequently in the form of inflammation of the cellu- 
lar tissue. In anteposition the u'erus is situated close to the symphysis, 
generally, above it and the condition is produced by growths or by accumu- 
lations in the pelvis which push up the uterus. The organ, once fixed 
in the abnormal position, remains. In retroposition the uterus is situated 
at a lower level, and close to the hollow of the sacrum. It results from 
inflammatory changes which contract and fix the organ; thus, a hemato- 
cele in its earlier stages may push the uterus forward into a state of ante- 
position, but later, as the collection becomes absorbed and organized, 
contractions occur which draw the organ backward. When the contrac- 
tion involves the region of the folds of Douglas or the uterosacral ligaments, 
the fundus of the organ will be pushed forward, and an anteflexion will 
be established. It is only when the uterus has previously been the seat 
of metritis and has become so rigid that it resists the tendency to flexion 
that it retains the retroposed position. 

Lateral position^ either right or left, is generally due to inflammation 
in the cellular tissue of the broad ligament. In the acute stage of inflam- 
mation the organ may be pushed to the side opposite to that on which 
the exudation occurs. As the condition becomes chronic, the inflamma- 
tory material contracts, and the uterus is drawn to the affected side. 
These displacements cause no special symptoms. The symptoms, when 
present, are due to the complications or conditions which have produced 
the displacement and are not a consequence of the latter. 

Diagnosis. The situation of the displaced organ is recognized by 
bimanual examination. The fixed position and situation are usually 
sufficient to establish the diagnosis. In lateral displacement the organ 
is not in a median position, and on manipulation moves more readily 
toward the affected side. In a woman in whom the abdomen is very fat 
or the abdominal wall quite rigid, the posterior dislocation is often diflGi- 
cult to differentiate from retroversion. The introduction of the sound 
would afford information, but the advantage derived from determining 
the position is insufficient to compensate for the danger from its use. 
Either the vaginal or rectal bimanual, practised while an assistant drags 
upon the cervix with a tenaculum or vulsellum, will generally afford a 
definite determination as to the character of the malposition. 

257. Torsion is generally associated with either a retroposition or 
a lateral position, and is due to an irregular contraction of the portion of 
the broad ligament which has been subject to cellular inflammation. 
This contraction twists the uterus upon its axis, so that the cornua may 
be turned anteroposterior instead of being situated laterally. The entire 
uterus can be thus twisted, so that, upon inspection, the os, instead of 
being transverse, will present an oblique or nearly anteroposterior line. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



449 



Torsion also results from the presence of growths in either broad ligament 
or of an ovarian tumor to which the tube is adherent. As the tumor 
enlarges it drags upon the uterus and twists it. This lesion is frequently 
overlooked, and presents no symptoms of special importance. 

258. Anteversion. In anteversion, the uterus is found with its 
fundus forward and the cervix directed backward or upward and back- 
ward. (Fig. 388.) The organ may be fixed in the abnormal position by 
complications, such as inflammation, which may cause adhesions between 
the fundus and anterior parietal peritoneum, or more frequently in the 
cellular tissues about the uterus, the cervix, or in the uterosacral ligaments. 
An inflammatory process of the uterosacral ligaments with a normal 




Fig. 388. — Anteversion of the Uterus. 

Uterus will produce flexion, but when the latter organ is stiffened by 
long-continued inflammation, anteversion results. The uterus is con- 
siderably increased in size; its walls are thickened and often rigid and 
firm. The normal flexion has disappeared, and the canal is perfectly 
straight. This position of the uterus is caused by increase of weight, 
and in severe versions the fundus will lie forward upon the bladder or 
against the symphysis, while the cervix may be directed upward and 
backward. 

Etiology. Any disorder which increases the weight of the uterus 
increases tendency to its antedisplacement. When the uterus has been 
the site of previous inflammation, particularly a metritis, this displace- 
ment is necessarily an anteversion. Metritis, subinvolution of the uterus, 
pelvic cellulitis, occurring in the posterior portion and in the uterosacral 
29 



450 



GYNECOLOGY. 



ligaments; fibroid growths in the fundus; ovarian growths — all may cause 
anteversion. 

Symptoms. Anteversion presents no characteristic symptoms. The 
symptoms are those associated with the complication by which it is pro- 
duced. The patient may complain of a sensation of distress, from 
pressure upon the bladder, of frequent micturition, and of pain or a dull 
ache over the region of the symphysis. 

Diagnosis. Anteversion is readily determined by bimanual palpation. 
The cervix is situated high posteriorly, and often reached with some 

difficulty, while the uterine body 
can be traced forward and is 
found to rest upon the bladder. 
Not infrequently the fundus lies 
well against the symphysis. The 
situation of the fundus in the an- 
terior . portion of the abdomen, 
the absence of any angle in the 
uterus, and its size, weight, and 
greater or less degree of immo- 
bility, definitely differentiate it. 

Treatment. As we have 
already seen, anteversion is a 
symptom or sign rather than an 
actual disease. It is a condition 
due to increased uterine weight, 
and treatment must necessarily 
be that which is applicable to 
the existing complication. The 
most common complication is 
inflammation, causing hypertro- 
phy or hyperplasia of the uterus, 
an irritative infiltration and pro- 
liferation of the tissue element. 
The inflammation condition may 
exist with or without adhesions. 
The treatment of anteversion, 
then, in the great majority of 
cases, is that of existing inflam- 
mation — hot vaginal douches, tampons medicated with agents which are 
expected to exert an influence in decreasing the size of the uterus. 
Frequently this decrease can be accomplished, to a considerable degree, by 
thoroughly dilating the uterine cavity with laminaria tents, followed by 
swabbing the interior of the organ with tincture of iodin, a saturated solu- 
tion of iodin crystals in 95 per cent, carbolic acid, or a saturated solution 
of iodoform in ether. Following such an application the decrease in size 
of the uterus may be promoted still further by iodoform gauze packing 
of the uterine cavity and a tampon of iodoform gauze in the vagina. 
This raises the organ to a higher level and promotes its circulation. 




Fig. 389. — Sims' Operation for Anteversion. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



451 




Fig. 390, — Abdominal Belt. 



Furthermore, the uterus can be dilated with graduated bougies, its cavity 
cureted, and applications made as suggested. Where the uterus is free 
from adhesions, it may be supported by a pessary. The pessaries which 
were devised for the purpose of elevating the fundus have not proved 
satisfactory. In some cases of heavy uteri the retroversion pessary is 
particularly serviceable, although it may seem a paradoxical instrument 
to employ in anteversion. It does, however, afford relief by holding the 
uterus at a higher level. Pelvic massage employed daily is of special 
value in promoting drainage, in facilitating metabolism, and in re- 
ducing the size of the uterus. Operations upon the cervix, amputation, 
or the repair of a laceration will excite such a process of metabolism as to 
decrease the size of the uterus. 
When the uterosacral ligaments 
have not become shortened 
through inflammatory processes 
causing an irremediable dis- 
placement, the operation devised 
by Sims may be practised. This 
consists in making a transverse 
denudation upon the anterior 
lip, another upon the anterior 
vaginal wall at a suitable dis- 
tance from it, and uniting these two surfaces by sutures (see Fig. 389). 
As a result of this operation the cervix is drawn toward the vulvar outlet, 
the fundus is tilted upward, and a more correct position is secured. When 
the uterus is fixed by more recent adhesions, in addition to the treatment 
already suggested, pelvic massage will prove beneficial. Two fingers in 
the vagina are hooked behind the cervix and press the fundus of the organ 
upward; while the external hand is rotated over it, the fingers pressing down 
along the uterine sides and in front, push the fundus backward. While 
the uterus is pushed backward with the fingers of the external hand and 
drawn forward with the fingers in the vagina, bands of adhesion are put 
upon the stretch and are manipulated to such an extent that their absorption 
is promoted. The manipulation of the uterus promotes absorption of 
inflammatory exudate within its walls, and thus assists in decreasing its 
size, so that by the time the adhesions are stretched and loosened, the 
uterus is so reduced that the patient is much relieved. In some cases, 
where a boring pain is experienced over the symphysis, the wearing of 
a cincture or belt (Fig. 390) will support the abdominal viscera and relieve 
the intra-abdominal pressure to such a degree that the ache or discomfort 
will disappear. 

259. Retroversion. In retroversion the uterus is turned with the 
fundus backward. (Fig. 391.) The cervix is directed forward against 
the posterior wall of the bladder. This displacement varies in degree 
according to the relations of the cervix and uterus to the axis of the vagina. 
The maximum degree is a backward displacement in which the fundus 
lies low in the hollow of the sacrum, with the cervix directed upward. 
Retroversion is recognized as an early stage of prolapsus. In this dis- 



452 



GYNECOLOGY. 



placement the intra-abdominal pressure is directed upon the fundus or 
upon the anterior wall of the uterus, which favors downward displace- 
ment, so that we usually find retroversion associated with a certain amount 
of descent. 

Etiology. The most frequent cause of retroversion is a lesion of 
pregnancy. Retroversion occurs in the unmarried or sterile woman, 
but much less frequently. It is produced by decreased support of the 
ligaments (particularly the uterosacral) , which permits the uterus to 
sag downward and to be rotated backward; the latter action is occasioned 
by a distended bladder. Finally the ligaments lose their muscular tone 
and the organ does not regain its normal position. Retroversion can be 




Fig. 391. — Retroversion. 

produced by traumatism, as when the person falls from a height and 
strikes upon the feet or, particularly, upon the buttocks, and by the 
presence of growths in the uterus or in the ovaries. 

Symptoms. Retroversion causes few symptoms. The discomfort 
in the majority of cases arises from complications. Patients may have 
marked retroversion without experiencing any inconvenience or being 
aware of the condition until it is brought to their knowledge. Inflam- 
matory complications produce a sensation of weight or dragging, as if 
everything were about to protrude when the patient stands or walks. 
The menstrual flow is increased, producing menorrhagia; occasionally 
there is an irregular, bloody discharge, or the intermenstrual intervals 
are shortened, or, as a result of the coexisting catarrh, the patient will 
have a profuse leukorrhea. The projection backward of the fundus 



DISPLACEMENTS OF THE PELVIC ORGANS. 



453 



and pressure of the cervix against the bladder cause a more or less fre- 
quent desire to urinate. Not infrequently there is an extension of the 
inflammation to the vesical mucous membrane, which produces cystitis. 
Pressure of the uterus upon the rectum increases the tendency to constipa- 
tion, interferes with the rectal circulation, and develops hemorrhoids 
and fissure of the anus. An injury of the anus or rectum under these 
circumstances is slow to recover, which makes it important, in cases of 
rectal disease, to ascertain the condition of the uterus before resorting 
to any operative interference. 

Diagnosis. Digital examination discloses the cervix uteri in the 
axis of the vagina, or looking forward and sometimes upward. Through 




Fig. 392. — Slight Degree of Anteflexion. 

the posterior vaginal fornix the examining finger recognizes a mass 
which is continuous on a straight line with the cervix. The bimanual 
examination discloses the absence of the fundus from the anterior fornix. 
The rectal bimanual affords an opportunity to explore the fundus and 
even the anterior surface of the uterus. (Sec. 262.) 

260. Lateral version is a form of displacement in which the fundus 
is situated to one side of the pelvis, while the cervix is directed toward 
the other. This condition is produced by cellulitis in the broad ligament 
and by intraligamentary growths, either fibroid or ovarian; in marked 
cases of inflammation contraction can occur in the base of one broad 
ligament and in its upper part on the opposite side. This produces a 
fixation of the uterus directly transverse to the pelvis, not unusually with 



454 



GYNECOLOGY. 



a certain amount of torsion. The lateral version causes no special 
symptoms, and is readily recognized by a bimanual palpation. 

261. Anteflexion. In anteflexion the uterus is bent upon its axis, 
with the fundus forward, while the cervix lies more or less in the axis of 
the vagina. The flexion may be but little more than normal (Fig. 392); 
indeed, any flexion which is fixed is an abnormal one, even though it 
may not be greater than the ordinary bending of the uterus. From a 
slight flexion we may have a very acute one (Fig. 393), in which the 
fundus and cervix seem to lie upon each other at an acute angle. The 
anterior wall of the uterus, at the point of flexion, undergoes a change 
in which there is a substitution of fibrous tissue for the muscle-wall. 




Fig. 393. — Acute Anteflexion. 

The posterior surface becomes exceedingly thinned where it bends over 
the anterior. (Fig. 396.) The anteflexion may be mobile or immobile. 
The former results from a heavy fundus when the cervix is in a more or 
less fixed position. Raising the fundus, we can tilt it backward, and 
leave the uterus in a position of retroflexion, so that at times the organ 
is anteflexed; at others, retroflexed. Not infrequently a diagnosis of 
anteflexion will be made when a subsequent examination by another 
person shows the uterus to be retroflexed. If the fact that the organ is 
mobile is not remembered, an error in diagnosis will be attributed to 
the first investigator. In the immobile uterus the flexion is fixed. 
Anteflexion, again, may be regarded as physiologic, pathologic, or in- 
different. A physiologic anteflexion is one which corresponds to the 



DISPLACEMENTS OF THE PELVIC ORGANS. 455 

normal condition of the uterus; a pathologic, one in which the flexion 
is more or less fixed or is greater than normal; while in an indifferent 
anteflexion the bending causes no symptoms. 

Etiology. Anteflexion is probably next to the most frequent form 
of uterine displacement, and it occurs less frequently in the married than 
do the retrodisplacements. It occurs with greater frequency in the 
unmarried or nulliparous woman, and is a result of congenital conditions, 
or, rather, those which are associated with the earlier development of 
the uterus. Anteflexion may be ascribed, first, to the long cervix of the 
puerile organ, the situation of which, in the vagina, necessitates the 
fundus bending forward over it. Second, inflammation in the utero- 
sacral ligament or in the cellular tissue posterior to the uterus, which 
draws the cervix upward (Fig. 397), promotes, in a flexible body, its 
falling forward, and the angle between the body and the cervix is in- 
creased. Third, the displacement arises fron locaHzed inflammation at 
the site of the placenta, when situated upon the posterior uterine wall. 
Involution is more rapid in the anterior, and the shorter wall becomes 
the string of the bow which bends the uterus forward. Fourth, ante- 
flexion is produced by growths in the fundus of the uterus. 

The symptoms most frequently attributed to anteflexion are sterility 
and dysmenorrhea; but when uncomplicated by inflammation, neither 
of these symptoms is present necessarily. The patient with marked ante- 
flexion generally suffers from chronic vesical distress. Pain occurs when 
the bladder is moderately distended, micturition is frequent, and generally 
there is a sensation of distress and annoyance which follows the evacua- 
tion. These symptoms, however, are frequently produced by inflamma- 
tion in the bladder, so the urine should be carefully examined. Dys- 
menorrhea has been attributed to an obstruction of the canal by an 
accumulation of material within the uterine cavity, which the organ has 
to go into labor to expel. As flexion does not cause dysmenorrhea when 
the lesion is uncomplicated by inflammation, it is evident that the latter 
is the cause of the symptom, and that the hyperemia prior to and coin- 
cident with menstruation produces pain during the distention of the in- 
flamed surfaces rather than an obstruction of the canal. Even in congen- 
ital conditions the dysmenorrhea does not occur with the first menstruation, 
but later, when there is distinct evidence of the development of inflamma- 
tory trouble. 

Diagnosis. Anteflexion is recognized by digital and bimanual palpa- 
tion. The cervix is situated in the axis of the vagina, and, by carrying the 
finger in front of it, a body is felt in the anterior fornix of the vagina, be- 
tween which and the cervix a distinct angle is recognized. During 
bimanual palpation this angle can to some degree be straightened, and 
the relation of the flexion to the cervix and body is more distinctly recog- 
nized. The flexion is particularly determined by passing the index- 
finger into the lateral fornix, first upon one side and then upon the other. 
By pressing from above we are able to recognize the lateral borders of 
the uterus and the absence of any growth. We can be in doubt as to 
whether the mass found in front is the fundus uteri or a fibroid growth 



456 GYNECOLOGY. 

attached to its anterior wall. Each condition may afford an equal-sized 
angle. The method we have already described, of passing the finger 
along the lateral aspect of the uterus, will enable us to differentiate them. 
By changing the position of the organ and pressing it well forward with 
the hand over the abdomen, we can outline the posterior surface of the 
fundus, and determine that its size and relations correspond to those of 
the cervix to the fundus, rather than to a growth. When the uterus is 
fixed, bimanual palpation is difficult. The position of the organ can be 
determined by the introduction of a uterine sound into the canal. The 
use of the sound, however, under these or any other circumstances, is 
fraught with so much danger that it is preferable to give an anesthetic 
if necessary for the further practice of the bimanual, rather than to 
make an intra-uterine exploration. 

Rectal palpation with the digital finger, while the thumb of the same 
hand enters the vagina against the cervix, with the other hand over the 
abdomen, enables us to bring the uterus definitely under observation. 

Treatment. Anteflexion requires treatment only when it is associated 
with symptoms, and these are usually the result of complications. The 
symptoms may be caused by complications incident to changes in the 
uterine structure itself, as inflammation either in its wall or in the sur- 
rounding structures. Inflammation may be incident to the various con- 
stitutional conditions, as a rheumatic or gouty diathesis, or the effect of 
neurasthenia, but in such cases the treatment may be constitutional or a 
combination of both constitutional and local measures. The most 
frequent symptoms associated with anteflexion are dysmenorrhea or 
painful menstruation, and sterility. However, that they are not necessar- 
fly the result of anteflexion alone is evident, from the many cases in which 
the patients with marked anteflexion have both menstruated painlessly 
and given birth to children. Patients suffering from dysmenorrhea 
associated with anteflexion should be encouraged to live an outdoor life. 
Hygienic measures are particularly important. The clothing should be 
suitable, and the extremities be warmly clad. Very frequently women 
who suffer from dysmenorrhea while in the North will be absolutely 
free from this symptom when residing in the South or in the Bermuda 
Islands. Measures should be instituted to improve general nutrition, 
obviate sluggish circulation, and to regulate the bowels. Such patients 
are often benefitted by bicycle-riding, playing golf, or anything which 
leads to an outdoor life. Pelvic or uterine congestion should be de- 
creased by the administration of iodids and bromids, the employment, 
particularly, a few days to a week before the menstrual period, of gel- 
semium or Pulsatilla, taking five drops of the fluid extract of gelsemium 
or ten drops of tincture of Pulsatilla, three or four times in the twenty-four 
hours, until the patient exhibits signs of its physiologic action. Thyroid 
extract is of value in these cases, when the drug is given in doses of 
three to five grains two or three times in the twenty-four hours. 
Douches, tampons, painting the vault of the vagina with tincture of 
iodin, gauze packing, and pelvic massage are all of service. The pes- 
sary, particularly the Graily-Hewitt (Fig. 125) or the Thomas anteflex- 



DISPLACEMENTS OF THE PELVIC ORGANS. 



457 




ion pessary (Fig. 126), which tilts up the fundus of the uterus, have 
had their advocates. Their efi&cacy, however, is somewhat doubtful. 
Pelvic massage is of special value in these cases, as the manipulation of 
the uterus serves to straighten the organ and promote a healthy condition 
of its circulation. 

When the condition of the patient is not improved by douches, tam- 
pons, or constitutional measures, the uterus may be dilated by the intro- 
duction of a laminaria tent. This procedure should be done with the 
most thorough aseptic precautions, with the vagina thoroughly 
cleansed, the cervical canal rendered as aseptic as possible. The 
tent itself should be sterilized, preferably by dry heat, although it 
may be placed for several minutes in 
a solution of iodoform and ether, in 
equal parts of alcohol and carbolic 
acid, or, better, in iodin tincture, prior 
to its introduction. The cervix should 
be seized with a double tenaculum, 
sponged with a solution of formalin, 
and by traction straightened so that 
the tent can be the more readily in- 
troduced. As large a tent as the 
caliber of the cervical canal will allow 
should be employed. The tent is re- 
moved in twelve to fourteen hours, 
after which the uterine cavity is irri- 
gated, if necessary cureted, swabbed with a saturated solution of iodin 
in carbolic acid or of iodoform in ether. The canal may or may not 
be packed with iodoform gauze. The dilatation with tents may be 
repeated at intervals until the tendency to displacement appears to be 
overcome and the uterine complication has subsided. Inflammation 
in the cellular tissue about the uterus, or in the tubes and ovaries, as 
evidenced by their enlargement and fixation in the pelvis, should be con- 
sidered as a contra-indication to the use of tents. Dilatation can be ac- 
complished by graduated bougies and their employment followed by 
curetment. Twenty-five years ago the employment of the stem-pessary 
was a favorite method of overcoming an anteflexion. The stem was one- 
eighth of an inch shorter than the uterine cavity; the patient was required 
to wear it for a considerable length of time. (Fig. 127.) The objection 
to its use is that it is a source of irritation, affords constant danger of in- 
fection to the uterine mucosa, and may lead to the development of more 
serious trouble. W. Gill Wylie advocated the use of a grooved stem of 
hard rubber or glass to serve as a drainage-tube. He and others still 
practise this method of overcoming the dysmenorrhea incident to acute 
anteflexion and claim marked improvement in many cases. The favor- 
ite treatment of Sims was a bilateral incision — occasionally one through 
the posterior lip. Unless precautions are taken to prevent it, the parts 
are reunited. Even when precautions are employed, cicatricial tissue 
forms, which subsequently causes distress, sometimes greater even than 



Fig. 3Q4. — Section Sho\ving Thinning of 
Cervical Walls at the Angle of Flexion. 



458 



GYNECOLOGY. 



the preexisting condition. The posterior lip can be split up to the angle 
of flexion and its cervical and vaginal lining membranes united by 
sutures, to prevent reunion. Occasionally, after such an operation, 
the cervix spreads out, owing to the intra-abdominal pressure, and the 
more delicate cervical mucous membrane is thus exposed to pressure 
and irritation, resulting in endometritis and formation of cysts of Naboth, 
which will require continuous treatment. Splitting the anterior lip has 
been advocated. This is performed by dissecting the bladder from 
the anterior wall of the cervix to the level of or above the point of 
flexion. A grooved director is then introduced into the uterus and the 
cervix is incised. As the incision approaches the os it is carried 




Fig. 395. — Anteflexion Associated with Contraction of Uterosacral Ligaments. 



around to the side of the cervix. The cervical mucous membrane is 
united to that of the vaginal wall. This enlarges the opening from the 
front and prevents obstruction, but is subject to the same objection made 
to the posterior operation, in that it exposes delicate surfaces to irrita- 
tion and subsequent inflammation. E. C. Dudley has devised an in- 
genious operation, in which he splits the posterior lip to or beyond the 
vaginal attachment; the surfaces are held apart by tenacula and the inci- 
sion is deepened upon the cervical side with a knife. A wedge-shaped 
piece is removed from each side, and the sutures are so introduced as to 
unite the edge or apex of the incision on each side with the base. By 
this method eversion of the cervical mucous membrane is prevented. 
(See Fig. 396.) The anterior lip of the cervix is then amputated, and 



DISPLACEMENTS OF THE PELVIC ORGANS. 



459 



the wound closed with transverse sutures, which push back the cervical 
orifice and straighten the canal. (See Fig. 397.) Nourse, recognizing 
that the flexion corresponded to the shorter wall, made a bilateral incision 
to the level of or a little above the angle of flexion. Traction is then 
made upon the posterior lip, whch results in straightening the canal. The 
new surfaces are apposed and secured with sutures, leaving the posterior 
lip longer. When the latter is half an inch or more in length, it is 
amputated by the flap method, thus making it the same length as the 




Fig. 396. 



-Dudley's Operation for Anteflexion, by Incising and Suturing the Posterior 

Lip. 



anterior lip. The raw surfaces are united by suture. (Figs. 398 and 
399.) When the elongation is short, it is left to contract. C. A. L. 
Reed advocated opening the abdomen and removing a wedge-shaped 
piece from the posterior wall of the uterus opposite the angle of flexion. 
This surface is closed by vertical sutures and restores the organ to 
normal position. Burrage advises, in proper cases, incision of the utero- 
sacral ligaments and the performance of a ventrosuspension, thus raising 
the fundus of the organ upward. 

262, In retroflexion the fundus is bent backward upon the uterine 



460 



GYNECOLOGY. 



axis, and, according to its degree, lies toward the rectum (Fig. 400) oris 
forced well down into Douglas' pouch. (Fig. 401.) The cervix is in the 
axis of the vagina. The retroflexion may be mobile or immobile, may 
be pathologic or indifferent, but never can be said to be physiologic. This 
form of displacement is very frequently a sequel of version. The uterus 
becomes retroverted and the abdominal pressure then drives the fun- 
dus downward, bending it upon its axis, forcing it into Douglas' pouch. 
(Fig. 402.) 





L 




Fig. 397. — Completion of Dudley's Operation, by Transverse Denudation and Suturing 

of the Anterior Lip. 



Etiology. Retroflexion is produced by metritis; subinvolution; in- 
flammation of the placental site, in the anterior wall of the organ ; fibroid 
growths in the fundus or anterior uterine wall (Fig. 403), parametric 
inflammation, or cellulitis of the anterior segment of the pelvic floor, 
which draws the cervix forward; localized peritonitis; or contraction 
following hematocele (Fig. 404) , by which the fundus of the organ is 
drawn backward. 

Symptoms. Retroflexion, - like the other forms of displacement, 
presents no special symptoms, when uncomplicated. It produces a 



DISPLACEMENTS OF THE PELVIC ORGANS. 



461 



sensation of weight and pressure, not infrequently pain in the region of 
the anus, an uncomfortable sensation down the posterior surface of the 
lower extremities, points of anesthesia over the thighs, congestion, partial 
obstruction of the rectum, obstinate constipation, and not infrequently 




Fig. 398. — Nourse's Operation by Splitting the Cervix and Resuturing the Incisions. 




Fig. 399. — Operation Completed. 

a sensation that the intestine is so obstructed that the bowel cannot be 
evacuated. Not unusually development of hemorrhoids, anal fissures, 
and more or less prolapse of the rectal mucous membrane follow. Men- 
struation is irregular and profuse, or the menstrual intervals are shortened, 
and leukorrhea is quite profuse. 



462 



GYNECOLOGY. 




Fig. 400. — Retroflexion of Slight Degree. 




Fig. 401. — Retroflexion of Extreme Degree. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



463 




Fig. 402. — Retroflexion Following Version. 




Fig. 403.— Retroflexion Produced by Fibroma of Anterior Uterine Wall. 



464 



GYNECOLOGY. 



Diagnosis. Digital examination discloses the cervix situated at a 
lower level in the pelvis, occupying the axis of the vagina or directed a 
little anteriorly; the finger in the posterior fornix recognizes a body 
slightly above, or even below, the cervix, which is rounded, may be 




Fig. 404. — Retroflexion the Sequel of Inflammatory Adhesions. 

movable or fixed, and somewhat larger than the normal fundus. Between 
it and the cervix is a distinct angle, though the structures can be traced 
from one to the other. The finger in the anterior vaginal fornix and the 
other hand over the abdomen discloses the absence of the fundus uteri 
from its normal position. The flexion is apparently increased by pres- 




FiG. 405. — Retroflexion Simulated by Posterior Uterine Myoma. 

sure^upon the cervix, and the fundus is driven more deeply into the cul-de- 
sac. By pressing the finger upward on either side of the uterus and 
cervix the lateral margins can be determined. Digital examination through 
the rectum enables us to pass directly over the fundus and to feel to some 



DISPLACEMENTS OF THE PELVIC ORGANS. 



465 



degree its anterior surface, which now becomes posterior. Retroflexion 
of the uterus can be confounded with fibroid growths (Fig. 405) situated 
in the posterior uterine wall, adherent ovarian growths (Fig. 406), or 




^2 Fig. 406. — Retroflexion Simulated by Small Ovarian Cyst in Posterior Cul-de-sac- 




Fig. 407. — Anteflexion and Retroflexion Simulated by Pehic Exudation. 

pehdc inflammatory exudation. (Fig. 407.) The introduction of 
the sound into the uterine canal, and its passage backward into the mass, 
would be definite evidence that a retroflexion exists; but, as in other 



466 



GYNECOLOGY. 



Uterine conditions, this procedure is fraught with so much danger as to 
condemn it. With a careful bimanual examination, as has been advised, 
either by the rectum, the vagina, or both, we are generally able to de- 
termine the relations of the uterus to the surrounding parts, and to fix 
the diagnosis absolutely. When the existence of pelvic exudate or im- 
mobility of the uterus and a resistant or thick abdomen prevent its 
accomplishment, the patient should be given an anesthetic. 

263. Treatment of Retroversion and Retroflexion. As retro- 
flexion is simply a bending of a version, we will, therefore, consider the 
treatment of these two conditions together. As the majority of other 
displacements are not characterized by symptoms, unless complications 
are present, so, in these conditions, symptoms are not manifest without 




Fig. 408, — The Retroverted Uterus Replaced; Patient in Dorsal Position. 

the existence of complications. However, in maintaining a retro- 
position the circulation of the organ is interfered with. This results 
in congestion and subsequently in more or less inflammation. There- 
fore the treatment of the complications is ineffective so long as the 
displacement remains. The relief of the inflammatory condition is 
expedited by maintaining the uterus in a correct position. Treatment 
largely depends upon the duration of the displacement, the changes 
which the structures have undergone, and the ability to replace and 
maintain the organ in proper position. No means for retaining the 
uterus in position are effective until it has been accurately replaced first, 
when it can be supported with relief of many of the distressing symptoms. 
Three methods are generally recognized as proper for replacing the 
organ. The first is the bimanual. The patient is placed in the dorsal 
position with her limbs flexed. Two fingers are introduced into the 



DISPLACEMENTS OF THE PELVIC ORGANS. 



467 



vagina, while the fingers of the other hand are placed over the abdo- 
men (Fig. 408.) The middle or long finger is passed into the pos- 
terior fornix of the vagina to press up the fundus, while the index-finger 
is carried in front of the cervix to push it backward. The pressure 
against the lower end of the lever carries the opposite end, the fundus, 
forward, until it can be grasped by the external hand and brought into a 
position of anteversion. In some cases the fundus of the uterus is caught 
beneath the promontory of the sacrum and cannot be dislodged readily. 
If the cervix, however, is grasped with a double tenaculum or vulsellum, 
and drawn down, while the fundus is pushed up with the finger in the 
vagina or rectum, the fundus uteri is readily displaced from beneath 
the promontory and the cervix can then be carried backward. 




Fig. 409. — Schultze's Method of Replacing an Adherent Retroverted Uterus, 

The second procedure consists in placing the patient in the genupec- 
toral position and using the Sims speculum to open the vagina. The 
atmospheric pressure balloons the vagina and the uterus is carried to the 
upper part of the canal. This procedure, however, does not of itself 
correct the position, as the uterus, though elevated, may still be retro- 
flexed or retroverted. The position, when uncomplicated, may be cor- 
rected readily by seizing the cervix with a tenaculum or vulsellum, and 
drawing it toward the vaginal orifice, and then carrying it backward 
and upward. The fundus is thus dislodged and the position corrected. 

A third procedure consists in the employment of the uterine sound. 
With the patient in the dorsal position, two fingers are introduced into 
the vagina and the sound, carried between them, enters the os and is 
introduced to the fundus and then rotated. The external end of the sound 
is carried through a wide arc so as to do as little injury to the internal 
mucous membrane as possible, while the handle of the sound is de- 
pressed and the finger in the posterior fornix pushes the fundus upward. 
This combined movement carries the fundus forward until it can be 
controlled with the external hand. In spite of the most careful precautions 



468 



GYNECOLOGY. 



the uterine mucosa will be injured by this method of procedure. It is 
exceedingly difficult to avoid the danger of the introduction of infectious 
material into the uterus, which necessarily favors the development of 
further complications. For such reasons, the sound should not be em- 
ployed, especially as every purpose attained by its use can be readily 
accomplished by methods already described. Various jointed sounds have 
been devised for the purpose of replacement of retrodisplaced uteri/ 
but these instruments are open to the same objections offered to the use 
of the ordinary sound. 

In adherent uteri none of these methods of procedure will accomplish 
the restoration of the displaced organ. When the adhesions exist be- 
tween the posterior uterine surface and the anterior rectal wall, the in- 
testine may be dragged up with the uterus and apparently permit it to 




Fig. 410. — Second Step in Replacing Uterus by Schultze's Operation. 



assume its normal position; but as soon as the supporting force is re- 
moved, the uterus is drawn back and, if mechanical efforts are employed 
to retain it in position, the fundus is bent backward and the retroflexion 
is greatly increased. If adhesions are present and they are not too firm 
nor of too long duration, pelvic massage affords a valuable method for 
overcoming their baneful influence and promoting their absorption. 
The massage should be supplemented by the use of tampons. In some 
cases the pressure of an air pessary within the vagina stretches the bands of 
adhesions, promotes their absorption, and supports the uterus. Schultze 
advocated a procedure which is very effective in overcoming recent ad- 
hesions. The patient is placed in the dorsal position, with the muscles 
well relaxed by an anesthetic. Two fingers are introduced into the 
rectum, while the thumb in the vagina against the cervix steadies the 



DISPLACEMENTS OF THE PELVIC ORGANS. 



469 



Uterus until the fingers in the rectum, one on either side of the fundus, can 
invert and draw down the bowel and separate it from the uterine surface. 
(Figs. 409 and 410.) As the adhesions are separated and the uterus is 
set free, the external hand grasps the fundus and draws it forward, 
breaking the remaining bands of adhesion. Care must be exercised in 
carrying out this procedure not to employ too much force, otherwise the 
intestine may be injured. There is more danger, however, of injuring the 
tubes or ovaries, when these organs are adherent. An adherent tube may 
be torn and liberate at the seat of inflammatory trouble, poison which, if 
of a purulent character, may cause a violent attack of pelvic or possibly 
general peritonitis. With purulent inflammation or pus collections in 
the tube excluded, the absorption and loosening of the adhesions of the 




Fig. 411. — Proper Position of the Pessary. 

ovary, tube, and uterus can be effected by pelvic massage. If the adhe- 
sions are extensive and the vagina tender, especially when its posterior 
fornix is more or less obliterated by the long duration of the displace- 
ment, the uterus can be temporarily supported by the employment of 
vaginal tampons, medicated or not, as the conditions require. The 
employment of continual pressure over the abdomen or within the vagina 
may be effected by shot-bags or the employment of rubber bags con- 
taining mercury. Three to five pounds or more of shot may be applied 
over the abdomen to make pressure over a mass of exudate and thus 
promote its absorption and the release of an adherent uterus. The 
absorption of the vaginal exudate may be expedited by the use of mercury ;. 
applied in a rubber bag. Such a weight introduced into the vagina., 



470 



GYNECOLOGY. 



with the position of the patient changed from time to time in order to 
subject different portions of the exudate to the weight, promotes absorp- 
tion and the consequent loosening of the uterus and pelvic structures. 
When the uterus is free from adhesions and, consequently, can be 
readily replaced, we can at once resort to the use of a pessary. (Sec. 112.) 
Some of the more prominent retrodisplacement pessaries are the Hodge 
(Fig. 120), Thomas, Munde (Fig. 121), and the Schultze (Fig. 130) 
instruments. The various modifications of the Hodge pessary consist 
of a posterior bar with converging side bars which are united by a shorter 
bar anteriorly. Laterally, the pessary has the shape of a letter S. The 
posterior bar is carried behind the cervix into the posterior fornix. In its 
modification by Thomas and Munde, the posterior bar is thickened, which 




Fig. 412. — Faulty Position of the Pessary. 

makes a larger mass in the fornix. The pessary does not support the 
body of the uterus on its posterior bar, but it so drags upon the posterior 
vaginal fornix as to pull against the cervix and lift it up, until the other 
end of the lever — the fundus — is held so far forward that the intra-abdom- 
inal pressure is directed upon the posterior uterine surface. This pulley- 
like action of the pessary is readily seen in Fig. 411, which shows the 
proper position of the pessary in relation to the uterus and vagina. It 
has already been emphasized that the pessary does not support the body 
of the uterus, and that the position of the organ must be corrected be- 
fore the introduction of the instrument. The result of an a;ttempt to 
employ the pessary to correct the position of the uterus can be seen 
in Fig. 412. It is very important that the pessary should not be unduly 



DISPLACEMENTS OF THE PELVIC ORGANS. 47 1 

long. When too much pressure is produced, ulceration of the vagina 
occurs, rendering the patient unable to retain it. If the instrument is 
too long, it may project from the vulva and cause irritation about the 
urethra or neck of the bladder, and much discomfort in sitting. The 
proper length of the pessary is determined readily by the introduction 
of two fingers into the vagina to measure the distance between the 
distended posterior vaginal fornix and the internal margin of the sym- 
physis. The proper width of the pessary is appreciated by determining 
the extent to which the fingers can be separated without undue lateral 
pressure in the vagina. The proper size of the instrument to be em- 
ployed is thus ascertained. While too long a pessary produces the 
conditions we have already mentioned, one too short allows the 
fundus of the uterus to fall backward over its posterior bar, in- 
creases the retroflexion and adds to the distress of the patient. It is 
difficult to maintain the pessary in place where the vagina is much 
relaxed. If the uterosacral ligaments are much elongated, and the pos- 
terior fornix distensible, the pessary will fail to maintain the uterus in 
its normal position. Moreover, it will permit the organ to drop back and 
rest upon the instrument. (Fig. 412.) Schultze designed the pessary 
known as the figure-of-8, which is very effective for such cases. This 
pessary laterally is similar in shape to the Hodge instrument, forming 
a letter S. The lateral bars of this pessary are twisted to form a figure-of- 
8, the upper loop of which surrounds the neck of the cervix and carries 
it upward, while the inferior loop is so broad that it receives support 
from the vagina and does not incline to prolapse. Should the figure-of- 
8 prove unsatisfactory, the sledge pessary of Schultze may be efficient. 
(Fig. 131.) Its posterior end has a bar curved forward, which rests in 
front against the cervix and holds it back, while at the same time traction 
is made upon the cervix through the distention of the posterior fornix 
by the upper part of the instrument. The pessary should be sufficiently 
broad to impinge against the side walls of the vagina to prevent its slipping 
down. It distends the vagina in three directions — in length, laterally, 
and in the anteroposterior direction. When adhesions are present, the 
pessary is badly borne and is harmful. It is at all times a foreign body 
and produces a certain amount of irritation in the vagina, which, to many 
patients, is a source of much discomfort; besides, it is not always efficient 
in maintaining the uterus. As it must be worn for months or even years 
to secure sufficient contraction to maintain the organ, many patients 
prefer to submit to operative interference. 

The pessary may be employed in retroversions due to subinvolution 
of the uterus subsequent to a recent delivery. In such cases the pessary 
will maintain the uterus at a higher level, promote the process of involution, 
and thus favor the maintenance of the organ in a replaced position after it 
has reached its normal size. It may be employed after adhesions have 
been broken up, by the Schultze method, or when we have been able to 
accomplish the loosening of the uterus by pelvic massage. Where re- 
trodisplacement has existed for some time, the posterior fornix of the 
vagina may be so shortened that a pessary cannot be worn. Such a con- 



472 



GYNECOLOGY. 



dition will require treatment by douches and tampons until the posterior 
vaginal fornix is stretched. Pessaries are also of little value in those cases 
in which the vaginal portion of the cervix has been destroyed by amputa- 
tion or as a result of repeated labors. ^ 

As the pessary is a foreign body, it is therefore important that explicit 
directions should be given regarding its management before this subject 
is dismissed. Directions have been given for the determination of a 
suitably sized instrument, and I would again emphasize the fact that the 
instrument should be neither too large nor too small. The former will 
cause pressure upon the surrounding parts, producing irritation, ulceration, 
loss of structure, and open avenues for the entrance of infection. A 
smaller instrument is easily dislodged from its position, does not serve any 



^ 



ROUNJ) 
LIGNIT. 




3UB-CUTAN£0Uj 
FAT 



APONEURO), 



f' C^CX 08 U QUE 



UiMAL N. 



Fig. 413. — Alexander Operation; Round Ligament Exposed. 

useful purpose, and may only serve to aggravate the condition. ^The 
patient should be directed to remove the instrument or have it removed if it 
causes increased discomfort, and return to the physician within a week at 
least after its introduction. He can then determine definitely whether the 
instrument is serving its proper purpose or causing any irritation. In 
neurotic patients too much attention must not be given to the instrument, 
otherwise the patient will manufacture a long train of distressing symp- 
toms and attribute them to its presence. The instrument is likely to in- 
crease the vaginal discharge, and for this reason it is important that" it 
should be kept clean. It is undesirable, however, to employ mineral 
astringents in the douche for this purpose, as they are likely to roughen 
the pessary, and cause it to irritate the vagina. A properly fitting instru- 



DISPLACEMENTS OF THE PELVIC ORGANS. 



473 



ment can be worn without the patient's being aware of its presence, but 
even though it causes no annoyance, she should be advised to have it 
removed at stated intervals — not exceeding three months — for cleanHness 
and to make sure that it is doing no harm. These rules apply to the hard- 
rubber instrument. Where the instrument is of the soft-rubber variety, 
it should be removed more frequently, as the discharges to some degree 
enter into the rubber, decomposition takes place, and a foul odor arises 
which is very annoying to the patient and to those with whom she is 
associated; moreover, it may cause systemic infection. 




Fig. 414. — Round Ligament Being Drawn Out. 



Operative procedures for the correction of retrodisplacements jof the 
uterus consist of extraperitoneal and intraperitoneal shortening fof the 
round ligaments, by abdominal or vaginal incision, and the construction 
of artificial ligaments, as in ventrofixation or ventrosuspension. Besides 
these, there are also numerous vaginal operative methods for correcting 
retroplaced uteri. 

Extraperitoneal Shortening of the Round Ligaments. Shortening of the 
round ligaments is an operation which was performed by Alexander in 



474 



GYNECOLOGY. 



December, 1881, and two months later by Adams, although the latter 
contributed the first publication. The operation had, however, been 
advocated by a Frenchman named Alquie, as early as 1840. 

The operation requires two incisions, and each consists of four stages: 
I. An incision six centimeters long, a little inside the pubic spine and 
above and parallel to Poupart's ligament, is made through all the tissues 
to the aponeurosis of the external oblique. (Fig. 413.) 




t'lG. 415. — Round Ligament Sutured. 

2. Exploration for the round ligament. This is disclosed by a small 
ball of fatty tissue which covers its end between the pillars of the exter- 
nal inguinal ring. Pressure upon the side causes the mass to protrude. 
A hook passed beneath this mass enables the operator to raise up the 
ligament. (Fig. 414.) It is then detached by a director, from the pos- 
terior adherent fibers which maintain its relation to the inferior part of 
the canal, after which it is seized with a pair of forceps and drawn out. 

3. Upon the completion of the first and second stages, on both sides, 



DISPLACEMENTS OF THE PELVIC ORGANS. 



475 



we proceed to the third, which consists in shortening and fixation of the 
ligaments. The ligaments are drawn upon until the fundus is brought 
under the pubes. This movement can be facilitated and rupture of the 
fibrous filaments avoided by previously placing the uterus in anteflexion, 
either by the sound or preferably by the aid of the fingers of an assistant. 
The ligaments are drawn out from four to ten centimeters, according to the 
resistance. When they become tense, they are maintained by an assist- 
ant, while a needle charged with silk, silkworm-gut, or catgut is made to 
traverse the external pillar, the ligament, and next the internal pillar. 
(Fig. 415.) Three sutures are thus introduced, one centimeter apart. 
(Figs. 416 and 417.) 




Fig. 416. — Continuous Catgut Suture Uniting Internal Oblique Muscle to Pou- 

part's Ligament. 

4. The wound is closed with silk or silkworm-gut sutures, dressed with 
gauze, and the parts so secured by bandaging as to prevent the wound from 
becoming exposed by the movements of the patient. The wearing of a 
Hodge pessary for two months following the operation is advisable, 
though some pr^er the tampon. Various modifications of this operation 
have been devised. Edebohls splits the entire length of the inguinal canal, 
draws the ligaments out at the internal ring, and closes the wound as in the 
Bassini operation. Newman makes an incision directly over the internal 



476 



GYNECOLOGY. 



ring, draws the ligament straight out, and secures it in the wound. Frank- 
lin Martin and Duret, of Lille, do not use sutures, but pass a pair of dres- 
sing forceps beneath the skin and subcutaneous tissue from one wound to 
the other, draw the ligament through, tie the two ligaments together in a 
knot, and close the tissues over the union. Cassati joins the lower ends of 
the lateral wounds with a curved incision, in which the crossed ends of the 
ligaments are united by continuous suture. Doleris employs the same 




RD.LIGMT. 



Fig. 417. — Return Layer of Suture Bringing External Oblique Muscle in Apposition. 



method, uniting the two ligatures with catgut sutures, after pulling them 
through, as in the method suggested by Martin. Goldspohn suggested 
and practiced stretching the internal ring and opening through the peri- 
toneum, so that the finger can be passed into the pelvis and break up ad- 
hesions about the uterus, ovaries and tubes. He has, however discontinued 
it as he feels assured it does not afford the same facility as is gained by 
other procedures. ., 

The advantages claimed for the Alexander operation are: i. The 
incisions being superficial or extraperitoneal, the risk of infection 
is less; as it is local, the danger of peritonitis is decreased. 2. The 



DISPLACEMENTS OF THE PELVIC ORGANS. 



477 



method of maintaining the uterus forward has less injurious influence upon 
a^'future pregnancy. 3. It imitates the natural support, in that the natural 
ligaments are employed. 4. No intraperitoneal adhesions can form. 
The disadvantages are: i. That two incisions are required. 2. The 




Fig. 418. — Wylie's Operation for Shortening tJtie Round Ligaments within the Abdomen. 

operation is limited in its application. It is only in those cases in which 
the uterus is mobile that we can practise this procedure. Consequently 
it has the further disadvantage in that we are not always able to determine 
definitely the existence of adhesions between the uterus and the anterior 




Fig. 419. — Mann's Operation for Intra-abdominal Shortening of Round Ligaments. 

wall of the rectum. Should such adhesions exist, the uterus drawn fonvard 
by the round ligaments is subject to forces which tend to render the opera- 
tion nugatory. 3. The round ligaments are sometimes so attenuated as 
to be of little use in maintaining the organ. In an operation of mine the 



478 



GYNECOLOGY. 



ligament on one side was apparently entirely absent. I found no vestige 
of it in the canal. I therefore opened into the peritoneal cavity and found 
that the round ligament had disappeared. 4. In cases of infection the 
infected ligament may slip back and carry infection beneath the perito- 
neum, where it will be difficult to reach, and, consequently, render the 
operation not altogether free from danger. 




Fig. 420. — Dudley's Operation of Desmopycnosis. 

Intraperitoneal Shortening of Round Ligaments. The round liga- 
ments are shortened within the peritoneal cavity by making an incision 
through the abdomen in the median line. This procedure permits the 
uterus to be drawn up, and the condition of the appendages to be ex- 
amined and treated, if necessary. Existing adhesions can be broken up 




Fig. 421. — Dudley's Operation Completed. 

and the round ligaments shortened by folding them. (Fig. 418.) Wylie 
suggests that two to four inches of the ligament be doubled up on each side 
and united by sutures, so the shortened ligament draws and holds forward 
the fundus. Mann grasps the broad ligament about the junction of its 
middle and outer third and folds the ligament in three parts which are 



DISPLACEMENTS OF THE PELVIC ORGANS. 479 

united by sutures. (Fig. 419.) By this method the ligament is well 
shortened on each side. A. P. Dudley, of New York, performed an opera- 
tion which he called desmopycnosis. (Fig. 420.) This is accomplished 
as follows: The abdomen opened, an assistant introduces two fingers 
into the vagina and pushes the uterus as high as possible in the pelvis, 
while the operator brings the organ through the abdominal incision. 
An oval denudation is made upon the anterior uterine wall, making sure 
that the bladder is not injured; then each round ligament is brought up to 
the portion of the peritoneal covering on the inner side, denuded to 
correspond with that on the uterus, and the three denuded surfaces are 
then united with catgut sutures. The sutures must be so adjusted as to 
pass sufficiently deep in the uterine tissue to secure against their cutting 




Fig. 422. — Gilliam-Ferguson Operation. Round Ligament Seized through Stab Wound. 

out before union has occurred. (Fig. 420.) This procedure holds the 
uterus forward in a position of anteversion. Ries cuts a slit through 
the anterior surface of the fundus, through which a loop of each round 
ligament, drawn out of its sheath, is carried and fastened. Bissell excises 
a portion of the round ligament and unites the cut ends with catgut 
sutures. Webster picks up a loop of the round ligament, carries it through 
the broad ligament beneath the Fallopian tube, and secures it to the 
posterior surface of the uterus. This procedure has been modified by 
Baldy, who ligates the uterine end of the round ligaments, incises each 
ligament external to the ligature, and carries the free end, rather than 
the loop, through the broad ligament and fastens it to the posterior 
surface of the uterus. All these operative procedures, however, act upon 
the strongest part of the ligament, leaving the weakest portion, that 
which occupies the inguinal canal, to be stretched out. Gilliam devised 
a procedure (Fig. 422) which consists in picking up the ligament, three or 
four centimeters from its uterine end, and carrying a loop of it through a 



48o 



GYNECOLOGY. 




Fig. 423. — Round Ligament Drawn through the Abdominal Wall. 




Fig, 424. — Section Showing Position of the Uterus with Completion of the Operation. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



481 



Stab wound in the lower part of the rectus muscle on either side, and there 
securing it. (Fig. 423.) This procedure divided the lower part of the 
abdomen into three apertures, through two of which coils of intestines 
were capable of being pushed and compressed to a greater or less degree. 
To obviate such danger Ferguson modified the operation by quilting together 
the peritoneal surface external to the point transfixed by the loop of round 
ligament. This ligature, when tied, closes up the gap in the peritoneal 
cavity external to the point through which the loop of the ligament is 




Fig. 



425. — First Step in My Alodification of the Gilliam Operation for Securing Round 
Ligament Support. 



brought out. With these parts secured, the uterus is held forward by 
a loop of the strongest part of the round ligament. (Fig. 424.) Simpson, 
through a median incision about one inch from the uterus, passed a 
suture through three-fourths of the round ligament, threaded both ends 
of this suture into a carrier, and through the slit made in the anterior 
layer of the broad ligament passed it directly forward beneath the peri- 
toneum of the vesico-uterine pouch to a point upon the anterior abdominal 
wall one and one-half inches external to the median line, and carried both 
ends into the peritoneal cavity. One end threaded into a sharp curved needle 
31 



482 



GYNECOLOGY. 



and thrust into the muscular structure, emerged upon the peritoneum, 
where it was secured by tying with the other end. I have combined the 
Simpson and Gilliam operation as follows: A curved incision, when 
possible, within the pubic hair line is made through skin, superficial fascia, 
and aponeurosis. The aponeurosis is loosened from the pyramidalis 
muscles and drawn upward (see Figs. 150 and 151), the recti muscles 
separated, and the peritoneum divided in the vertical line. After freeing 
adhesions and giving proper attention to the condition of the ovaries and 




Fig. 426. — Second Step, Showing Ligament Fixed with Hemostat while Temporary Ligature 
is Carried Beneath Anterior Leaflet of Broad Ligament with a Deschamps Needle. 

tubes, a suture is passed beneath each round ligament, one inch and a half 
external to the uterus. (Fig. 425.) The ends of the suture upon one side 
are threaded into the eye of a Deschamps needle having a rather long arm. 
(Fig. 426.) The round ligament external to the suture is seized with a 
hemostat and given to an assistant with the direction to keep it taut. An 
opening is made into the anterior layer of the broad ligament, just below 
the insertion of the suture, and through this opening the needle carrying 
the ends of the suture is introduced and carried outward between the layers 
of the broad ligament until the parietal peritoneum is reached, when the 



DISPLACEMENTS OF THE PELVIC ORGANS. 



483 



latter is drawn inward and the point of the instrument plunged through 
the abdominal parietes, emerging upon the aponeurosis. The suture ends 
upon each side are withdrawn from the Deschamps needle, and secured 
by a hemostat. Seizing the suture upon one side and drawing upon it to 
make it tense, a pair of pointed scissors, closed, is thrust alongside the 
ligature and the blades separated, when, in the majority of cases, the trac- 
tion causes a loop of the ligament to follow the withdrawal of the scissors. 
Where it does not at once follow, it can be teased through by pressing back 




Fig. 427, — Operation Completed; Differs from Gilliam-Ferguson in Having No Internal 

Sutures. 

the tissues as traction is being made. (Fig. 427.) Having thus brought 
a loop of each ligament through the wall, the loop is secured to the apo- 
neurosis by catgut sutures. Previous to securing the protruded loop see 
that the uterus is in proper position. If it is not, the portion' of ligament 
next to the uterus can be pulled upon to the necessary degree to accomplish 
the object. The ligaments secured, the wound is closed by a continuous 
chromic catgut suture in the peritoneum and muscle edges. This suture 
should be drawn over firmly enough to hold in apposition the peritoneal 
surfaces and not strangulate the muscle structure. A second suture 



484 



GYNECOLOGY. 



closes the aponeurosis and a third the skin surfaces. The greatest care 
must be exercised to prevent the accumulation of blood above or beneath 
the aponeurosis, for such an accumulation is readily infected and the for- 
mation of an abscess will result in a weakened ventrum — possibly in 
sloughing of the aponeurosis. Bleeding vessels should be ligated, and 
where there is a tendency to oozing, drainage should be employed. This 
method of treatment possesses the advantages that: i. It affords ample 
opportunity for the recognition and treatment of diseased conditions of 
the pelvic structures; 2. No opportunity is added by the operation for the 




Y 



i^^ 



Fig. 428. — Sutures Introduced for Ventrosuspension. 



formation of disturbing pelvic adhesions; 3. The natural condition is more 
closely imitated and the uterus maintained in position by ligaments 
capable of evolution and involution. 

Ventrofixation and ventrosuspension are terms applied to the opera- 
tion devised by Olshausen, and modified by Kelly, for establishing an 
artificial ligament for the purpose of maintaining the uterus forward. 
The operation consists in an incision in the median line, through which the 
uterus is exposed and its fundus sutured to the parietal peritoneum at the 
lower angle of the wound. Generally two or three buried sutures of silk, 
silkworm-gut, catgut, or silver wire are used. (Fig. 428.) The first 
suture is passed through the peritoneum about one centimeter from the 
wound margin, through the fundus uteri near its center, and brought out 
through the peritoneum of the opposite side of the wound. A second 
suture is similarly placed about eight millimeters behind the first. To 
prevent the peritoneum from being dragged away from the abdominal 
wall it is included in the abdominal suture. Since the first edition of this 
book I have modified my method of performing this operation by intro- 



DISPLACEMENTS OF THE PELVIC ORGANS. 485 

ducing a silkworm-gut suture through the fundus of the uterus and the 
abdominal walls, which is subsequently tied externally. A needle, carry- 
ing a chromic catgut suture, is introduced through the aponeurosis of the 
lower angle of the right side, through the fundus of the uterus, near the 
silkworm-gut suture, and brought out through the peritoneum of the 
opposite side. Two subsequent turns of the suture are passed through 
the edges of the peritoneum and the fundus of the uterus, after which the 
peritoneal wound is closed with the remaining suture. Following the 
introduction of silkworm-gut sutures through all the tissues above the 
peritoneum, this same catgut suture is carried back through the apo- 
neurosis and tied at the lower angle of the wound. Therefore the uterus, 
peritoneum, and aponeurosis are all held by the one suture, and only a 
single buried knot remains in the incision. The silkworm-gut sutures 
(including the one through the fundus uteri), are then tied, which would 
bring in apposition and secure the skin edges. The stay or lower suture 
of silkworm-gut may be tied over a pledget of gauze to prevent cutting the 
skin, and should be permitted to remain for two weeks. This operation 
establishes between the uterus and parietal peritoneum, a ligamentous 
band which is sufficiently strong to maintain the uterus forward and yet 
not interfere with its mobility. Where it is preferable — as, for instance, 
after the climacteric, or in patients from whom both ovaries have been re- 
moved — that the uterus should be more firmly fixed to the abdominal wall, 
it is better that the peritoneum should be pushed back so that the sutures 
bring the muscle structure directly in contact with the fundus of the uterus. 
Such a course secures a firmer union and, therefore, the uterus is held more 
closely to the parietal wall. The procedure we have described permits 
thorough exploration of the pelvic cavity, the separation of adhesions, and 
the fixation of the uterus through a single incision. The procedure has 
been greatly modified. By some, the sutures are placed in the anterior 
uterine wall. The majority of operators insert them in the fundus — the 
first suture in the line of the Fallopian tubes, and the second a little behind 
it, thus throwing the uterus forward in slight anteflexion. The purpose 
of the operation of ventrosuspension is to establish a ligamentous union, 
which will permit a certain amount of uterine mobility. Consequently 
the uterus is attached only to the peritoneum, rather than to the muscle 
wall. To avoid the buried suture, F. Martin has suggested using the 
urachus, and when it is not well defined, a loop of peritoneum is carried 
from below upward through a buttonhole slit in the fundus and included in 
the sutures closing the wound. Bovee employs a portion of muscle apo- 
neurosis. These modifications, however, have no special advantage. 
The fixation has been accomplished through a transverse incision above 
the symphysis. This incision only divides the skin and superficial fascia. 
A vertical incision is then made through the aponeurosis, muscle wall and 
peritoneum. The uterus is brought forward and secured by two silkworm- 
gut sutures through the fundus. These are brought out through the mus- 
cle wall and segment of integument below the transverse incision. The 
remaining portion of the vertical wound is closed with catgut and the 
transverse incision in the skin with a continuous intercuticular stitch of 



486 GYNECOLOGY. 

silk. The suspensory stitches are tied over a gauze roll and permitted to 
remain two weeks . Ventrosuspension has the advantages already suggested, 
that it permits the inspection of the condition of the peritoneal cavity, 
the treatment of diseased appendages, the separation of adhesions, and the 
fixation forward of the uterus in a position which is unlikely to give distress. 
It has the following disadvantages: i. It has been found to interfere to 
some degree with subsequent gestation and labor, the patient complaining 
of more or less pulling and distress during the progress of gestation. 
Sometimes this is so marked as to cause abortion or premature labor. 
When the band of fixation is short, large, and firm, it may prevent enlarge- 
ment of the uterus and produce thinning of the posterior wall, which will 
increase the danger of rupture and afford obstacles to the normal progress 
of parturition. A firm band of adhesion, during pregnancy, after the 
performance of ventrofixation, may cause a condition simulating a bifid 
uterus. I have, in several instances, opened the abdomen during preg- 
nancy and cut the band in order to permit the uterus to develop properly. 
Furthermore, I have seen patients in whom I felt that such a procedure 
was advisable. In one instance I was called in consultation to see a 
woman who had had a ventrosuspension performed and who was in labor 
at full term. The anterior wall of the uterus and cervix were apparently 
doubled up, forming a shelf upon which the fetus rested with an arm 
protruding. The attendants, after vigorous efforts to turn the child, had 
cut off this arm. The fetus was lying in a transverse position, and a part 
of the body had engaged. After considerable difficulty I succeeded in pass- 
ing a cephalotribe upon the body of the child, with which I crushed the 
spine and delivered first the lower extremities, and then the trunk and 
head. 

2. The operation is not free from danger. I had the misfortune to have 
one patient in whom a large portion of intestine slipped below the band of 
adhesion immediately following the operation. This became strangulated 
and caused death. Similar cases have been reported by Lindfors, Jacobi, 
Olshausen, and others. The accident in my case occurred almost immedi- 
ately after the operation, and, although the patient suffered greatly, it was 
attributed by her attendants to hysterical excitement following the anes- 
thetic, and, when recognized, the condition of the patient was such as to 
preclude any hope of recovery. It would not require great imagination, 
when one sees these bands of adhesion, to appreciate the possibility of 
strangulation occurring at periods more remote from the operation, and 
numbers of such instances are recorded. 

3. The buried sutures of silkworm-gut, silk, or silver wire may become 
a source of irritation, either from immediate infection or later 
inflammatory changes, and cause a sinus to extend through the abdominal 
wall and give rise to an unpleasant discharge. Such a sequence, of 
course, annoys both patient and surgeon until the offending cause — the 
buried sutures — have been removed or have become disintegrated. Such 
a sinus may keep up for months or even years. The sutures can occasion- 
ally be fished up and removed. For this purpose I know of no instrument 
better adapted than the hook of the ear-spoon devised by the elder Gross 



DISPLACEMENTS OF THE PELVIC ORGANS. 487 

for the removal of hardened wax from the ear. If this instrument is 
ineffective, the surgeon may find himself obliged to reopen the wound. 
Frequently the offending ligature will be found deep in the pelvis, at the 
end of a band of adhesion. To avoid this difficulty I have employed the 
chromic catgut suture with a single knot. 

Burrage has advised ventrofixation for the treatment of immobile 
anteflexion. Through an abdominal incision he divides the uterosacral 
ligaments close to the uterus and secures the fundus to the abdominal wall. 
Schmidt, of Cologne, frees the anterior uterine wall from the bladder by 
dissection, excises a wedge-shaped piece with its point directed toward the 
cervical canal, and unites the surfaces by sutures. This draws the uterus 
forward in a position of anteflexion. 

Vaginal Operations. The ease with which the pelvis can be entered 
through the vagina has led to the adoption of various operative procedures 
through that canal to hold the uterus forward. One of the earliest opera- 
tions performed through the vagina is known as the Schiicking. This 
consists in passing an instrument, curved, for an acute anteflexion, to the 
fundus, from which a concealed needle is driven through the anterior 
vaginal fornix. This needle carries back a ligature, which, when tied, 
fij^es the uterus in a position of anteflexion. Care must be taken to push 
the bladder to one side to avoid injuring it. Injury of the intestine has also 
occurred. The ligature is permitted to remain for two or three weeks, 
when the resulting inflammatory changes will fix the uterus in anteflexion. 
The procedure is objectionable in that it is a blind operation, and injury, 
therefore, may be unavoidable. Instruments have been devised to push 
the uterus against the anterior abdominal wall and thrust needles carrying 
ligatures from its cavity by which the fundus can be fastened; but these 
are open to the same objection. They are blind procedures. 

Vaginal fixation devised by Diihrssen, subsequently practised and modi- 
fied by Mackenrodt, consists in making a vertical incision through the 
anterior vaginal wall to the cervix, when the bladder is pushed off until 
the peritoneum is reached. Without opening the latter a suture is intro- 
duced, and by it the uterus is pulled forward. A second suture, placed 
higher, near the fundus, is employed to maintain the uterus forv^ard by 
bringing its ends through the edges of the vaginal incision. Mackenrodt 
modified the operation by opening through the peritoneum and intro- 
ducing the sutures at a higher level, thus securing the fundus or anterior 
wall to the vaginal incision. The peritoneal and vaginal wounds were then 
closed. This operation was very largely practised for a time, but it soon was 
recognized that it was likely to cause much distress and discomfort during 
the progress of gestation. Moreover, it often produced profound dystocia, 
which imperiled the lives of both mother and child. For these reasons the 
operation is practised rather infrequently now. \^ineberg and Wertheim, 
through a simflar incision, seize the round ligament some three centimeters 
from the fundus uteri, pass a ligature beneath it, and bring the ends of this 
ligature out through the vaginal walls on either side of the vertical incision. 
The ligature is then tied. This holds the round ligament down against the 
vagina, and, consequently, fixes the uterus forward. The round ligaments 



488 GYNECOLOGY. 

also have been shortened through the vagina by performing the Wylie or 
Mann operation upon them. I have sutured the round ligaments to the 
anterior surface of the uterus through the vaginal opening. The operation 
of Ries consists in pulling a loop of the round ligament through a slit in the 
anterior wall of the uterus. This method has been described under ab- 
dominal procedures, but was devised to be performed through the vaginal 
incision. Through a posterior colpotomy by a vertical incision, Freund 
and Gottschalk shortened the uterosacral ligaments. The incision was 
made from just behind the cervix downward, toward the rectum. The 
peritoneal cavity was opened and a ligature introduced on each side to 
separate the surfaces. From this opening a ligature was carried through 
the middle of the uterosacral ligament, and one end of it through the 
posterior surface of the cervix. The ligature thus introduced on each side 
was tied, which drew the cervix upward and backward. Consequently 
the other end of the lever, the fundus, was thrown forward. A modification 
of this procedure has been extensively practised by Bovee, of Washington, 
who is an enthusiastic advocate of it. He shortens the ligament without 
opening the peritoneum. Pryor advocated a transverse incision in the 
posterior fornix of the vagina, through which he broke up adhesions, 
carried the uterus forward, and packed gauze into the posterior cul-de-sac. 
Then with a tampon he pressed the cervix well upward and backward. 
The subsequent adhesion of the cervix in this position leads to correction 
of the malposition. 

264. Lateral Flexion. Lateral uterine bending may be dextro- 
fiexion or sinistroflexion. The position of the cervix is more or less 
fixed and the fundus of the uterus is drawn to one side by cicatricial con- 
traction, or is pushed to the opposite by a large exudate, an intraliga- 
mentary fibroid growth, or an ovarian cyst. No special symptoms 
characterize the state; the diagnosis is readily determined by the methods 
already cited for the determination of other forms of displacement. 

265. Complications Associated with Displacements. It has been 
noted, in discussing the individual forms of displacement of the uterus, 
that they rarely produce symptoms themselves, and, when it is considered 
that the organ involved, in its normal condition, weighs less than an ounce, 
that its circulation is so extrinsic that the organ can be bent forward or 
backward without injury thereto, it is difficult to see why so much stress 
has been placed upon these displacements. 

The development of a complication, however, by which the circulation 
is obstructed, changes the whole aspect of affairs. The most frequent 
complications of uterine displacements are : 

Endometritis. 

Metritis. 

Salpingitis. 

Oophoritis. 

Cellulitis. 

Peritonitis. 

Other complications are : 

Ectopic gestation. 



HH 



DISPLACEMENTS OF THE PELVIC ORGANS. 489 

Ovarian or myomatous tumors. 

Ptosis of the abdominal viscera. 

These complications are most frecpently primary as regards the pro- 
duction of symptoms, though, as in prolapsus, they may be secondary in 
the sense that the displacement lessens the resistance to infection. 

Prognosis of displacements will depend upon their degree and the ex- 
istence of complications. In the earlier stage of the displacement, when 
the distress arises from increased weight of the organ, the mere correction 
of the position and the maintenance of the organ corrected wall bring about 
a decrease in its size and afford relief. After the displacement has existed 
for some time, it is complicated by chronic inflammatory changes, which 
will absolutely prevent any procedure from maintaining the organ in its 
proper position. The symptomatic phenomena, however, can be relieved 
and the patient practically restored to health. 

General Treatment. It will be seen, from a discussion of the different 
forms of displacement, that I am disinclined to believe that uncomplicated 
displacements are likely to produce symptoms. Of course, I can readily 
understand that when a patient has prolapsus, with the uterus protruding 
from the body, it necessarily produces disturbance and is subject to 
unusual irritation from its abnormal location. The small size of the uterus, 
when normal, and the manner in which it receives and discharges its blood- 
supply, render it difficult to conceive how the mere displacement of so 
movable an organ should be provocative of the serious symptoms which 
frequently have been attributed to it. The most frequent complications 
of uterine displacement are inflammatory processes and their sequelae, 
which cause increase in the size of the organ, its fixation by extensive 
adhesions, and interference with the performance of the function of the 
adjacent viscera. The treatment, then, must largely consist in the correc- 
tion of the existing complication. Experience has disclosed, however, 
that when such complications exist, their treatment is most effective when 
associated with measures directed to maintain the uterus in proper position. 
The methods of procedure most effective to accomplish this purpose are 
both local and constitutional, such as massage, electricity, and mechan'cal 
procedures. The patient should be suitably clad, and wear clothing free 
from undue constrictions about the waist. Her skirts should be supported 
from the shoulders. The bowels should be regulated carefully, and the 
bladder not permitted to become overdistended. Peri-uterine inflamma- 
tion and extensive exudates can be ameliorated and absorption expedited 
by the employment of pelvic massage. This is best performed by a daily 
seance of five to ten minutes or more, after the more severe distress and 
pain have been relieved. Occasionally the vault of the vagina may be 
painted with tincture of iodin, and in the intervals between the massage, 
tampons, medicated preferably with an antiseptic solution containing 
glycerin, shou'd be worn. The tampon maintains" the uterus at a higher 
level, promotes the absorption of exudation, facilitates involution, and 
thus favors its maintenance in a normal position. Vaginal douches. 
hot rectal enemas, hot sitz-baths, or the application of heat over the ab- 
domen or pelvis in the form of hot sand or a peat bath will be found 



490 GYNECOLOGY. 

beneficial. Pressure over the abdomen, particularly where a mass of 
exudate is recognized, will promote its absorption. This action often- 
times causes such an exudate to melt entirely away. Pressure can be 
effected by the use of a shot bag, by which three to five pounds or more of 
shot are retained over the affected surface. When the uterus is freely 
movable or the adhesions have been absorbed, the organ can be main- 
tained in its proper position by a suitable pessary. It should, however, 
be recognized that the uterus must be replaced in its proper position first. 
The pessary does not act as a corrective agent, but only as a crutch to 
support and maintain the uterus in its corrected position. Pessaries are 
generally made of soft and hard rubber, sometimes of wire coated with 
soft rubber. Soft-rubber instruments absorb the discharges from the 
vagina, decompose, become exceedingly foul, and cause a very disagree- 
able odor. While the pessary is worn it is important that the vagina 
should be irrigated daily. Solutions of the inorganic salts should not be 
employed for irrigation, as they deposit upon the surface of the pessary, 
cause it to roughen, and thus lead to abrasion and ulceration. The 
pessary must not be either unduly large or too small. An overlarge 
instrument makes pressure, causes ulceration, and the formation of granu- 
lations, which may envelop the pessary and finally cause it to become 
embedded in cicatricial tissue. Too small an instrument permits the uterus 
to fall back over it or the pessary itself to twist around and thus prevent its 
being of any service. 

Summary. In anteversion and anteflexion of moderate degree con- 
stitutional measures to improve the general health, the regulation of the se- 
cretions, enforced rest during menstruation, with dilatation, curetment, 
and the establishment of proper drainage will be means sufficient to estab- 
lish a symptomatic cure. Generally when anteflexion is acute and dys- 
menorrhea is marked, curetment will generally be of only temporary 
benefit and should be followed by splitting the posterior lip and suturing 
the surfaces, as advised by E. C. Dudley, or the insertion and retention 
of a Wylie drain. Retroversion and retroflexion are capable of pro- 
ducing marked influence upon the general health, but should not be 
considered as indicating the practice of special procedures unless they are 
productive of symptoms. The correction and maintenance of the proper 
position of the uterus is indicated as a preliminary treament of any 
complication, and retroversion, associated with recent subinvolution, 
unless complicated by perimetritic adhesions, should be considered an 
indication for the use of the pessary, provided the organ can be replaced. 
Where the pessary is not well borne in retroflexion and the uterus freely 
movable, the Alexander operation may be employed. The great fre- 
quency with which inflammation and more or less adhesion of the uterus 
occurs greatly limits the number of cases to which this operation is appli- 
cable. I would prefer to make the median incision, for it permits thorough 
examination of the pelvic viscera, existing adhesions to be separated, and 
diseased conditions of the ovaries and tubes to be treated. The great 
majority of operations for shortening the round ligaments within the abdo- 
men utilize the strongest portion of the ligament and leave its weakest part 



DISPLACEMENTS OF THE PELVIC ORGANS. 49 1 

undisturbed, with the probability of a redevelopment of the displacement. 
The modification of the operations of Gilliam and Simpson, which I have 
devised, seems to me the most desirable, as it accomplishes all that the 
Alexander operation could do. Moreover, it has the advantage over the 
operation of ventrosuspension in that it affords no opportunity for the 
formation of adhesions to serve as a trap by which a knuckle of intestine 
may become fixed and obstructed. My experience leads me to the per- 
formance of the operation known as ventrosuspension or ventrofix:ation 
less and less frequently. Of the vaginal operations, the ones pursued by 
Vineberg and Bovee are the most serviceable. The other vaginal opera- 
tions have proved unsatisfactory, for many of the patients thus operated 
upon have experienced trouble during subsequent pregnancy. Prolapsus 
uteri is a condition which should receive early consideration. The longer 
the displacement is permitted to remain unantagonized, the greater are 
the chances that it cannot be completely restored. The first stage of 
uterovaginal prolapse can be corrected by the employment of a suitable 
pessary. One should be employed which will maintain the uterus in a 
position of anteflexion or anteversion. The early stage of vagino-uterine 
prolapse should be considered an indication for the prompt retraction of 
the relaxed vaginal walls and the restoration of the perineum. The 
accompanying cystocele should be treated by an excision of the redundant 
vaginal portion of the septum. This surface should be sutured in a trans- 
verse direction in preference to the suture that is sometimes advocated, 
known as the Stolz suture, which shortens the vagina in every direction. 
The importance of having a long anterior vaginal segment is seen in its 
influence in maintaining the cervix at a higher level, consequently throwing 
the fundus forward. In the later stages of prolapsus the vaginal plastic 
operation should be supplemented by an abdominal procedure to maintain 
the organ forward. This may be accomplished by shortening of the round 
ligaments and of the uterosacral. When the latter are so extenuated as to 
render them unserviceable, the cervix may be held back by a suture on 
either side starting at the beginning of the broad ligament at the brim of 
the pelvis and follows the posterior surface of the broad ligament at 
intervals until it reaches a point posterior to the cervix in Douglas' pouch 
before it is tied. 

After the climacteric, especially when the uterus shows a marked tend- 
ency to descent, fixation of the organ is desirable. In very extensive 
prolapsus or in elongation of the supravaginal cervix the fundus uteri 
should be amputated, and the stump can then be secured to the upper part 
of the broad ligament or to the anterior abdominal wall. Very frequently 
the condition will be complicated by an extensive hernia through Douglas' 
pouch. Then an extensive vaginal plastic operation, combined with a 
ventrofixation, will not necessarily prevent the development of this condi- 
tion. The hernia may be obviated, however, by suturing together the fold 
of Douglas over the rectum and the remaining part of each fold 
to the side of the rectum. Enteroptosis may be still further prevented by 
fastening the colon to the abdominal parietes. My experience has led me 
to condemn the Freund operation as one of no value. 



492 



GYNECOLOGY. 



264. Inversion of the uterus is a condition in which the peritoneal 
and mucous surfaces are reversed, the latter covering a tumor situated in 
the vagina. Inversion can be partial or complete and presents three 
different forms. In a partial inversion the body of the organ is de- 
pressed and inverted until it reaches the cervix, but without dilating the 
latter. It is known as inversion intra-uterine. (Fig. 429.) Next, the 
fundus protrudes through the cervix, the unin verted portion of the latter 
forming a cuff at the upper part of the vagina. This is inversion intrava- 
ginal. (Fig. 430.) In the third form the entire uterus is inverted, and 
frequently the vagina with it, the uterus hanging outside the vulva. This 
is inversionextravaginal. (Fig. 431.) 

Now in each form of inversion there may be combined a partial or 
total inversion of the vagina, so that the view that the third form only is 





Fig. 429. — Partial Inversion of the Uterus, 
Showing Three Degrees. 



Fig. 430. — Intra vaginal Inversion; Three 
Degrees. 



necessarily combined with prolapsus is unjustifiable. A trifling degree of 
inversion or partial turning in of the uterus is called invagination. This 
may be a mere depression, over which the mucous surface becomes convex, 
while the peritoneal surface forms a depression or concavity. As this 
depression continues, the proximity of the tubes and round ligaments to 
the ligamentum ovarium draws these structures into the opening. The 
ovaries may rest upon the funnel-shaped depression, while the tube is 
necessarily, for a part of its extent, drawn into the cavity. The cavity, 
with its enlarged opening in the peritoneal cavity, is called the inversion 
funnel. Usually this funnel is not quite the depth of the ordinary length of 
the uterine cavity. If the inversion continues for some time, secondary 



DISPLACEMENTS OF THE PELVIC ORGANS. 



493 



phenomena result, from retrogressive processes, but the uterus returns to 
its normal size. The inverted mucous membrane is covered with epithe- 
lium; the neck of the uterus is small, generally surrounded by a cuff of 
tissue — a cervical ring — derived from the cervix, which has not been com- 
pletely inverted. The longer the inversion exists, the more considerable is 
the congestion. Edematous enlargement, and thickening form the mis- 
proportion between the narrow inversion funnel and the enveloping cuff 






Fig. 431. — Extra vaginal Inversion; Three 
Dej^rees. 



Fig. 432. — Nonpuerperal Inversion Fib- 
roid Tumor Attached to the Fundus 
Uteri. 



of thecervix. Wenot infrequently find diseases of the adnexa. The orifice 
of the tube situated in the vagina readily can be the avenue for the passage 
of infection into the deeper structures. The uterine inner surface of the 
tubal mouths is exposed, the projecting mucous membrane is frequently 
rubbed and irritated, so this door stands open for the entrance of germs, 
and infection can take its way through the tubal mucous membrane or 
by the lymphatics to the deeper tissues, producing endosalpingitis, sup- 
purative processes in the ovary, or purulent pelvioperitonitis by extension 



494 



GYNECOLOGY. 



of infection from the connective tissue. In ordinary conditions we can 
have involvement of the cellular tissue from such infectious processes. 
Alterations in the peritoneal covering of the inversion funnel occur, 
which render the condition more or less fixed. 

Etiology. Inversion generally arises from two causes : i . From puerperal 
conditions, relaxation, or partial paralysis of the uterus during the process 
of labor, especially the third stage of labor; and, 2. The nonpuerperal form, 
in which the uterus is displaced by the presence of a fibroid tumor at- 
tached to the fundus. (Fig. 432.) These two conditions are very much 
alike in the clinical form of an inversion, but are very different in their 




Fig. 433. — Palpation of an Inversion of the First Degree. 

manner of development. Puerperal inversions are much more frequent 
than those which arise from the presence of growths. They are in the 
proportion of nine to one. Total inversion is rare. How much more 
frequendy the partial form occurs is difficult to determine, as often partial 
inversion resulting from the presence of growths is overlooked. Puerperal 
inversion, in some cases, is produced by traction upon the cord in the efforts 
to deliver the placenta. By faulty pressure over the uterus the fundus 
may be inverted, and in the paralyzed condition may be grasped by the 
deeper structures and the inversion progress until it is completed. A short 
cord is an occasional cause for inversion. The traction is made upon the 
cord at a time when the uterus is relaxed and least resistant. Traction 
upon the fundus and subsequent uterine contraction very rapidly complete 



DISPLACEMENTS OF THE PELVIC ORGANS. 



495 



the displacement. Inversion rarely occurs spontaneously. Overdisten- 
tion of the cervix by a large fetus frequently causes such relaxation as will 
permit inversion to occur readily. It will be a matter of interest to know 
whether, in the cases in v/hich inversion has occurred, the placenta has 
been attached near the fundus of the uterus. 

Symptoms. Inversion causes characteristic symptoms. The patient 
generally complains of severe pain, which is continuous, sometimes for 




Fig. 434. — Palpation of an Inversion of the Second Degree. 



days; sometimes a pulling sensation is felt in the vagina. Immediately 
following the dislocation a severe hemorrhage occurs. This continues 
in noteworthy strength the first day of the puerperium. It does not 
completely disappear, but may continue much longer. Later, it appears 
intermittently, but the suspension of discharge rarely corresponds in its 
duration to the normal intermenstrual interval. During the interval 
there is a profuse mucous discharge from the genitalia. The profuse 
blood discharge may cause the death of the patient from acute anemia, or 
it may occur later from septic infection. In some cases spontaneous 



496 



GYNECOLOGY, 



reinversion has taken place in the course of the year. The condition may 
be suspected from these phenomena. 

Diagnosis. Inversion will be suspected from the severe pain, the more 
or less continuous hemorrhage, and the absence of the fundus uteri when 
the hand is placed upon the abdomen. Digital examination discloses a 
globular mass which fills up the vagina and is encircled by a cuff-like ring 
at its upper part. This ring is situated at the external os. (Fig. 434.) 
Placing the hand over the abdomen and making deep pressure, the fundus 
of the uterus is found to be absent from its normal situation, and, instead. 




Fig. 435. — Appearance of Inversion of the Third Degree. 

a funnel-shaped excavation is recognized, which is ordinarily sufficient to 
determine the diagnosis. (Fig. 435.) In the chronic condition the uterus 
resumes its normal size, presents a globular or pear-shaped mass in the 
vagina, surrounded at its upper part by a distinct cuff or ring, and the 
sound will pass into this the same distance on all sides. Bimanual exami- 
nation discloses above a funnel-shaped depression. This depression can 
be determined more readily by drawing upon the fundus of the uterus and 
introducing the finger into the rectum, when it can pass over the neck and 
directly into this funnel. The ovaries and tubes are recognized near or 



DISPLACEMENTS OF THE PELVIC ORGANS. 



497 



upon its margin. The speculum shows the vaginal tumor smooth, 
glistening, and highly reddened. Sometimes at its lower angles the open- 
ings of the tubes can be recognized. While a vaginal examination may 
afford a suspicion of the character of the disorder, the diagnosis is in- 
complete without a bimanual investigation which involves the rectum and 
belly cavity. When the abdominal walls are very thick and palpation is 
not determined readily, the introduction of a sound or a catheter into the 
bladder and of a finger into the rectum will determine definitely the pres- 
ence or absence of* the uterine body. Inversion of the uterus is sometimes 
confounded with fibroid polypus which has been extruded into the vagina. 
(Fig. 436.) A fibroid polypus may have a broad-based pedicle and the 






Fig. 436. — a. Inversion of the Uterus, b. Fibroid Polypus. 
Stenosis of the Cervical Canal. 



c. Fibroid Polypus, with 



tumor may present a shape very similar to that of an inverted uterus. As 
it is covered with mucous membrane, the superficial similarity may be 
marked. Of course, a fibroid tumor will show no orifice of the Fallopian 
tubes, but the latter are not always distinguished. Sensation in the fibroid 
is a little less marked than in the inverted uterus, but is not sufficiently 
definite to afford a foundation for diagnosis. The sound carried around 
the cuff of the inverted uterus passes on all sides an equal distance. With 
fibroid tumor it would pass into the uterine cavity at one side. (Fig. 436, b) 
Occasionally, however, the cavity of the uterus may be so stenosed that the 
sound will not enter, and the diagnosis may then be uncertain. (Fig. 436, c) 
If we grasp the mass and draw it down, the finger in the rectum will 
disclose, in the one case, the cup-shaped depression of the inverted uterus; 
and, in the other the body of the uterus lying above the neck of the 
32 



498 



GYNECOLOGY. 



growth. In a partial inversion, associated with fibroid growth, we may 
not be able definitely to determine the condition until we proceed to 
operation for the removal of the mass. (Fig. 437.) 

Treatment. There is a difference in the treatment of the two forms 
of inversion. In the puerperal condition all that is necessary is to re- 
place the uterus, when it will remain, while in the nonpuerperal form it 
is necessary to remove the growths which have caused it. Re-inversion 
is comparatively easy immediately after the occurrence. Occasionally, 
the opening of the vagina with the patient in the genupectoral position 
will permit replacement by atmospheric pressure. Often pressure 
against the fundus with the hand or fingers in the shape of a cone will 
be sufficient to carry the hand directly into the cavity of the uterus and 




Fig. 437. — a. Submucous Fibroma, h. Partial Inversion, c. Partial Division of the 

Uterus. 



accomplish its complete re-inversion. When the inversion has existed 
for some time and has become chronic, various methods .can be em- 
ployed for replacement. These measures may be manual, instrumen- 
tal, or operative. 

The manual treatment consists of a veritable taxis on the inverted 
organ as in hernia, and both hands are necessary. The left hand over 
the abdomen supports the uterus, while the right replaces the inversion. 
Courty introduced one or two fingers into the rectum and hooked them 
over the end of the uterus which fixed it more solidly. The other hand 
was introduced partly or wholly into the vagina. Taxis is exercised in 
various directions; thus, it is central, lateral, or peripheral. Taxis is 
called central when the pressure is made against the fundus, or median 
part of the organ (Fig. 440) ; lateral, when it is exercised at the level of 
one or the other uterine cornu (Fig. 441) ; and peripheral when the pres- 
sure is exerted on the reflex parts (Fig. 442.) The latter is exemplified 



DISPLACEMENTS OF THE PELVIC ORGANS. 



499 



when the fundus is seized in the palm of the hand. The fingers pass to 
the fundus of the vagina and spread it out, stretching the funnel while the 




Fig. 438. — Prolapsus Uteri without Inversion. 




Fig. 439 — Inversion of the Uterus — Extra vaginal. 

fundus is pushed against it. The procedure can be rendered more effec- 
tive by traction on sutures inserted in the cervix from the vagina. 

If taxis has been tried and found ineffectual, resort may be made to 



500 



GYNECOLOGY. 




Fig. 440. — Central Taxis. 




Fig. 441. — Lateral Taxis. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



501 




Fig. 442. — Peripheral Taxis. 




Fig. 443. — The Use of the Air Pessary to Reduce an Inversion. 



502 



GYNECOLOGY. 



instrumental reduction. A number of instruments for this purpose have 
been devised. The air pessary of Gariel introduced and distended ex- 
erts a hydrostatic or aerostatic pressure against the fundus and pushes it 
upward, while the vaginal walls, by their traction, pull apart the cervix. 
This soft pressure in some cases may be sufficient to accomplish the grad- 
ual reduction of the organ. The pessary can be introduced and a bandage 
so applied as to maintain the pressure against the crevix. (Fig. 443.) A 
vaginal tampon of iodoform gauze for twenty-four hours is sometimes 
more effective than the pessary. Pressure is sometimes employed against 
the fundus by an instrument with a cup-shaped end, into which the fundus 
fits. A spring upon its external surface induces an elastic pressure. 
(Fig. 444.) This procedure is more effective when combined with 




Fig. 444.- — Reduction of Inversion with White's Apparatus. 

Marcy's suggested insertion of two or more ligatures in the cervix, by 
which traction can be made upon it, while pressure is made against the 
fundus. Thomas advised opening the abdomen and dilating the cer- 
vix with an instrument similar to a glove-stretcher, while pressure is 
made against the fundus. (Fig. 445.) This procedure was successful in 
one case and fatal in another. It has been suggested to introduce 
the index-finger of one hand into the rectum, and that of the other into 
the bladder, hooking them into the funnel-shaped depression of the uterus, 
while the thumbs are pressed against the fundus. 

Where the patient has passed through the puerperium the inversion 
can without doubt be accomplished with less traumatism by the pro- 
cedure suggested by Kiistner. This consists in a transverse incision 
into Douglas' cul-de-sac through the posterior fornix of the vagina 
through which the index-finger of the left hand is inserted into the 



DISPLACEMENTS OF THE PELVIC ORGANS- 



503 



inversion funnel. Re-inversion may be attempted with the thumb 
of the same hand against the fundus. As the procedure is rarely success- 
ful, it is better at once to split the posterior uterine wall, in the median 
line, by a longitudinal incision, to within two centimeters of the fundus 
when re-inversion will be comparatively easy as resistance has been re- 
moved. After the uterus has been re-inverted it can be drawn down and 
a number of sutures introduced through the vaginal opening which should 
then be closed. Hirst advises a cut through the vaginal portion of the 
cervix only. 




Fig. 445. — Intraperitoneal Dilatation of the Uterus. 



If the inversion has existed for a number of years, it is questionable 
whether the changes in both mucosa and uterine wall are not such as to 
render of doubtful utility the retention of the organ when replaced. 
Then its removal should be considered advisable. The operation of 
hysterectomy should be done through the vagina and may be partial 
or complete. When limited to amputation of the fundus, precautions 
must be taken to guard against re-inversion of the stump with a resulting 
hemorrhage into the peritoneal cavity. By traction on the uterine body 
in the vagina its posterior surface is exposed, permitting a transverse 
section through the posterior cervical wall. The upper portion should 



504 



GYNECOLOGY. 



be secured by traction sutures or double tenaculi. Through this opening 
the vessels may be secured with compression forceps, and the amputation 
completed. The vessels are secured by passing a ligature with a needle 
beneath them on either side and firmly tying it. The peritoneal surfaces 
of the stump should be united with chromic catgut sutures as a final step 
in the operation. Complete hysterectomy in such cases is readily per- 
formed by splitting the inverted uterus when the separation of the two 
halves exposes the ligament containing the vessels which can be ligated 
readily by passing a ligature under each half with a needle. The uterus 




Fig. 446. — Incision of the Posterior Uterine Wall Preliminary to Reduction of an Inversion. 

is then removed flush with the vagina, the peritoneal surfaces united 
by continuous sutures, after which the vagina can be sutured. 

When the inversion is due to the presence of tumors, the operator 
may content himself simply with the removal of the growths and the 
re-inversion of the organ; or when the organ is very extensively involved, 
it may be necessary to remove the fundus with the growth. The possibil- 
ity of partial inversion should always be kept in mind in operating upon 
partial extrusion of growths from the uterine cavity. Numerous cases 
are recorded in which a fibroid polypus or growth has been removed by 



DISPLACEMENTS OF THE PELVIC ORGANS. 



505 



the wire ecraseur, and examination subsequently disclosed that a portion 
of the uterine wall was removed, causing an opening into the abdominal 
cavity. With growths projecting into the vagina, the preferable procedure 
is a careful enucleation of the tumor. The tumor is depressed and held 
while the enucleation is performed under the eye, so that, even though 
an inversion has occurred, by hugging the tumor closely we prevent 
breaking through the wall of the uterus. 

267. Displacements of the Appendages. Displacements of the 
ovaries and tubes are very common with backward uterine displacement. 
Inflammatory troubles in the tubes cause them to drag lower from increased 
weight, and they are found behind the uterus in Douglas' pouch. (Fig. 
447.) Frequently both tubes may be situated in this position, and, 




Fig. 447. — Prolapsus of Ovary and Tube behind Ulerus. 



united at their abdominal ends, form a single tumor, which contains pus 
or serum. The tubes are dislocated by their attachment to growths; 
ovarian, fibroid, or broad-ligament cysts may draw the tube up into the 
abdominal cavity and almost double its length. The most frequent 
dislocation of the ovaries is downward, into Douglas' cul-de-sac. This 
prolapse can occur as a consequence of retrodisplacement, or, indepen- 
dent of it, from elongation or rupture of the infundibulopelvic ligament. 
The dislocation can be occasioned by enlargement of the ovary, or the 
hypertrophy may be secondary to the displacement. The complication 
of retrodisplacement with ovarian prolapse is a source of additional 
distress and annoyance to a patient, as the tender ovarian structures 
are subject to pressure from the heavy uterus and from the passage 
over them of the contents of the bowel. In this situation they are also 



5o6 GYNECOLOGY. 

subject to pain and distress during the act of coition, often rendering it so 
painful that the act is dreaded by the patient. 

Symptoms. Prolapse of the ovary is generally associated with chronic 
inflammation, either as a primary or secondary condition. The symp- 
toms from which the patients suffer are necessarily those which to some 
degree are occasioned by the chronic disorder. In addition to this fact, 
however, the patient suffers distress during fecal evacuation, during 
the act of coition, in walking, and on standing. The ache and distress 
are sometimes so severe as to render the patient unable to assume or 
retain the upright position; a condition of semi-invalidism from the in- 
fluence upon the nervous system is engendered similar to that present 
in chronic ovarian inflammation. There are no symptoms characteristic 
of tubal displacement. 

Diagnosis. Prolapse of the ovary, when freely movable, is readily 
determined by bimanual palpation. A mass can be felt posterior to the 
uterus in Douglas' pouch, which varies from the size of an almond to 
that of a small orange. These masses can be pushed up. As they rise 
in the pelvis, they fall toward the side corresponding to the affected ovary, 
and drop backward as soon as the force is removed. When the ovary 
is enveloped and the pelvis filled with inflammatory exudate it is more 
difficult to determine its situation and, in fact, it may not be discovered 
until after the abdominal cavity is opened. Frequently tubal enlarge- 
ment with adhesions can be recognized as extending around the side of 
the uterus on its posterior surface, and the organs are more or less fixed. 

Treatment. Inflammatory conditions of the tube involving the 
ovaries should receive — when the tubes alone are affected — the same 
treatment. Prolapse of the ovary associated with chronic ovaritis, in 
which the ovaries are very much enlarged, is best treated by extirpation. 
When the enlargement is simply due to prolapse, causing more or less 
ovarian edema, the organ should be brought up and fixed in its proper 
position. Frequently shortening the round ligaments or ventrofixation 
will bring with it restoration of the position of the ovaries. When these, 
however, do not rest upon the posterior surface of the broad ligament, 
but drag backward into Douglas' pouch, the infundibulopelvic ligaments 
can be shortened, the external end of the ovary stitched to the 
posterior surface of the broad ligament near its upper part, or as has 
been suggested, a puncture can be made in the thin tissue between the 
tube and round ligament and the ovary pushed through and the open- 
ing closed so that this organ subsequently rests upon the ligament. 
Efforts have been made to maintain the ovary in its restored position 
by mechanical means, but in my experience they are usually ineffective. 
The ovary slips behind a pessary, though it have a thick bar, becomes 
pinched, and adds to the patient's distress. Often when the ovary is 
caught behind the instrument, the patient will be unable to move for a 
few minutes, owing to the severe pinching of the inflamed organ. 

268. Genito-urinary Hemorrhage. The advisability of consid- 
ering hemorrhage under a separate heading or division may be questioned, 
when under all circumstances its presence is an indication of the existence 



DISPLACEMENTS OF THE PELVIC ORGANS. 507 

of disease rather than the actual palpable disorder. However, my 
experience has caused me to believe that in the diseases of women the 
gravity of this symptom is not always appreciated fully, and this failure 
will be better overcome if the subject is given the importance of a separate 
consideration. 

Site and Varieties. Hemorrhage may arise from any portion of the 
genito-urinary tract and from the vessels within the adjacent cellular 
tissue. It can occur at any age, though prior to puberty it takes place 
but rarely, except from trauma. The significance of hemorrhage is 
largely dependent upon the age at which it makes its appearance. Hem- 
orrhage is called open when the blood escapes from the urethra, vagina, or 
through external injuries; concealed, when within the abdominal cavity 
or in the cellular tissue. In the latter, also, it may be denominated as 
circumscribed. A discharge of blood mixed with urine is known as 
hematuria. An excess of bloody discharge synchronous with the regular 
menstrual period is menorrhagia; while bleeding of an irregular character 
is metrorrhagia. A collection of blood in the cellular tissue is a hematoma; 
when in the tissues of the vulva or vagina, it is called a vulvovaginal 
thrombus or hematoma; into the cellular tissue about the uterus, an 
extraperitoneal hematocele; an accumulation within the peritoneal cavity, 
which is encysted or closed in by peritoneal adhesions, is described as 
an intraperitoneal hematocele. Hemorrhage into the structure of the 
ovary, when small, is known as an ovarian apoplexy; and when large, 
or frequently repeated, so the ovarian stroma is practically destroyed, 
and the collection forms a blood cyst, it is called an ovarian hematoma. 
A collection of blood in one of the hollow organs is known, in the 
Fallopian tube, as a hematosalpinx; in the uterus, as a hematometra; and in 
the vagina, as a hematocolpos; or when the collection is so large as to in- 
volve all, it is denominated a hematocolpometrosalpinx. Further dis- 
tinctions are retro-uterine, circum-uterine, and ante-uterine hemat- 
ocele, according to the situation of the blood collection — behind, about, 
or in front of the uterus. 

269. Hematuria is blood mixed with the urine, and is engendered by 
urethral caruncle, polypi, vegetations, fissures (the latter situated about 
the internal meatus), and malignant disease of the canal. It occurs in 
acute and chronic cystitis, associated with more or less vesical ulceration, 
and in the aggravation of the disorder occasioned by the presence of 
vesical calculi. Malignant growths or villous projections from the vesical 
mucous membrane are a prolific source for the occurrence of blood in the 
urine. It is often produced by injury, inflammation, or malignant dis- 
ease of the ureters or kidneys. Stone in the pelvis of the kidney frequently 
causes bloody urine. Occasionally blood appears in the urine as a 
result of constitutional conditions. So frequently is it associated with 
malarial infection as to give rise to the term malarial hematuria. 

Symptoms and Diagnosis. The blood may be mixed with urine, 
giving it a dark, smoky, often almost black appearance, or may precede or 
follow the act of micturition, as a few drops of free blood mixed with the 
urine or in the form of a small clot. The clots may be bright and recent, 



5o8 GYNECOLOGY. 

or darkened by longer retention within the urine. Unmixed blood comes 
from an injury or disease of the urethra; frequently a few drops or a 
small clot will follow urination when caused by a fissure of the meatus. 
When bleeding is occasioned by disease or injury of the bladder, the urine 
is not constantly bloody. An evacuation may be perfectly clear and the 
next be bloody. 

The cause of the symptom is ascertained by careful examination. Dis- 
orders of the urethral orifice are recognized by inspection of the canal, 
by palpation, and, if necessary, by inspection through an endoscope or a 
urethral speculum. A fissure at the internal urethral orifice causes severe 
pain upon palpation of the urethra. 

Inflammation of the bladder — cystitis — is recognized by painful and 
frequent micturition and attacks of profuse bleeding. The microscope 
reveals the cellular elements of the blood and degenerating epithelium 
in the urine. Where there are growths or foreign bodies palpation dis- 
closes thickened walls, increased tenderness, and possibly the mobility 
of a foreign body or calculus. Microscopic investigation of the fluid 
evacuated is of great value. Not infrequently the bladder maybe the seat 
of profuse bleeding, the blood becomes coagulated, and the clots interfere 
witn the collection and evacuation of the urine. 

Disease of the ureter and pelvis of the kidney may produce bloody 
discharge. Irrigation of the bladder permits the character of the urine 
from the kidney to be determined. Through the speculum the ureteric 
orifice often will be seen as a pouty, more or less abraded elevation, from 
which bloody urine is seen to issue. Catheterization of the ureter will 
determine the character of the secretion in the respective kidneys and 
the existence of disease in one or both of the organs. Calculi in the 
renal pelvis are generally a source of pain in the region of the kidney. 
Generally the pain is felt along the course of the ureter, not infrequently 
over the distribution of the genitocrural nerve. 

Treatment of hemorrhage is the same as that of the condition pro- 
ducing it. Hemorrhage from the bladder and urethra must be recognized 
as of importance. 

When trouble cannot be discovered in the urethra and bladder, the 
treatment should be directed to the disease in the pelvis of the kidney. 
Before proceeding to internal measures, constitutional conditions should 
be excluded. If necessary, the blood should be examined for the presence 
of the malarial plasmodium. The determination of malaria should 
indicate the use of antimalarial remedies. Bleeding may be arrested 
by the employment of astringents — tannic and gallic acids, hydrastis, 
and hamamelis; cotarnin hydrochlorate, gr. ss — j every three hours; 
ergotin, gr. j — ij four times daily; ol. erigeron, gtt. v— xx every three hours; 
gelatin in lo per cent, jelly by the stomach, or 2 to 3 per cent, solution in 
salt solution by hypodermoclysis. Tyson advises ferri persulph., gr. 
1/4— 1/2, as very effective. 

Continuation of bleeding associated with renal calculus should in- 
dicate operation for its removal. Operation will be a conservative course, 



DISPLACEMENTS OF THE PELVIC ORGANS. 509 

for the continuance of the disorder necessarily results in renal degenera- 
tion and destruction. 

270. Genital hemorrhage or bleeding is a term employed to 
describe bleeding which makes its exit externally, and may arise from any 
portion of the genital tract. Bleeding of slight character — a few drops — 
which will occasionally soil the clothing, will be a source of great anxiety 
to a nervous patient and should be considered an indication for a careful 
investigation by her physician. Such bleeding may arise from irritation 
of the vulva, warty growths, scratching induced by pruritus, from caruncle 
of the urethra, papillary growths and granulations of the vestibule or 
vaginal mucous membrane, lacerations, abrasions or erosions, or beginning 
malignant diseases of the vagina or cervix, inflammation of the endometrium, 
or changes incident to gestation or parturition. More severe bleeding 
or hemorrhage is induced by injuries of the vulva caused by falling and 
striking against a sharp object or by kicks or blows; these injuries cause 
very severe hemorrhage when the bulb of the vestibule is injured. Hemor- 
rhage is also incident to malignant disease of the labia or clitoris, severe 
injuries of the vagina, or extensive lacerations of the cervix. In- 
terstitial endometritis, fibroid growths encroaching upon the uterine 
cavity, and epithelioma, carcinoma, and sarcoma of the uterus are fre- 
quent causes. Hemorrhage from the genital tract may also result from 
disease outside of the canal which interferes with its circulation, as, in- 
flammatory exudate, cellulitis compressing the vessels of the pelvis and 
interfering with the return circulation, displacements, extra-uterine preg- 
nancy, intraligamentary tumors of the ovary or of ihe uterus, inflamma- 
tion of the Fallopian tubes, chronic inflammation of the ovaries, and 
constitutional conditions (as disease of the heart, of the kidneys, or of the 
liver) which affect the circulation in the uterus. The circulation is very 
often temporarily influenced by the development of zymotic diseases. 
Severe uterine hemorrhage may occasionally usher in an attack of typhoid 
fever. Disturbance -of the process of gestation by hemorrhage may 
indicate the occurrence of abortion or of premature labor, 07 may follow 
abortion or labor where the secundines or portions of the placenta are 
retained. 

Diagnosis. The determination of the existence of external hemor- 
rhage, of course, presents no difficulty. It is exceedingly important, 
however, that we should be able to recognize its etiology and source. 
This will often be found difiicult. No physician does justice to his patient 
who permits her to bleed without subjecting her to a careful examination 
in order to ascertain the cause. Not infrequently patients will object 
to the necessary examination. Such a patient should be given to under- 
stand plainly that the physician cannot continue to treat her unless she 
affords him an opportunity to know the existing conditions. He will do 
himself less injury by absolutely refusing to treat the case than he will 
if he yields to the patient's objection and endeavors to palliate an un- 
recognized disease. Unfortunately, many patients have an idea that 
hemorrhage at or near the climacteric is a condition to be expected, so 
if free bleeding occurs at this period, they attribute it to the coming change 



5IO GYNECOLOGY. 

of life and continue to endure it. Members of the medical profession, 
I find, are responsible for this misconception, as frequently they advise 
the patient that the bleeding is incidental to her period of life, therefore, 
when this has passed over, the hemorrhage will cease. Such a statement, 
however, only calms the patient and favors a transition from the existing 
state to another and perhaps more serious one. Moreover, when the 
discovery of the actual condition is made, the time for radical measures 
has elapsed. The occurrence of hemorrhage incident to local or con- 
stitutional conditions makes it incumbent upon us to examine carefully 
every organ of the body to be certain of its cause. 

In every woman who suffers from hemorrhage, where we are able 
to eliminate constitutional conditions, and where we can discover no 
disorders in the tissues about the organ or any disease of the cervix to 
explain the cause, the uterine cavity should be thoroughly explored. 
The previous history of the patient will enable us to ascertain whether 
the bleeding is due to the retention of products of a recent gestation. 
Bimanual examination will generally reveal even small growths. Such 
a condition will be manifested by localized areas of enlargement or re- 
sistance in the organ. Some of these growths, being pedunculated, 
can be moved about in the uterine cavity to a limited degree. Combined 
palpation also affords information as to the possibility of malignant 
disease. The latter occurs more frequently in the cervix, and when it 
exists in the body, it causes more or less hardening and sense of resistance 
from the presence of infiltration. This, of course, depends somewhat 
upon the associated reactionary inflammation. If the disease involves 
only a portion of the lining membrane of the uterus without the infiltra- 
tion extending into the wall, the bimanual examination will not reveal 
the induration. Therefore it will be necessary to explore the uterine 
cavity, preferably with the finger. The finger within the uterus and 
the hand over the abdomen enables one to outline and determine definitely 
the thickness and rigidity of the wall and the extent of induration as well 
as the general condition of the uterine mucous membrane. In the non- 
puerperal uterus, however, one cannot readily employ digital exploration 
of its cavity without a previous dilatation. 

Dilatation may be accomplished by a variety of methods, one of which 
is the employment of mechanical dilators or of graduated bougies. This 
procedure affords an excellent opportunity for the employment of thera- 
peutic measures within the uterus, but sufficient dilatation of the organ 
cannot be secured thus to allow the introduction of the finger without 
tearing and inflicting serious injury to the cervix. The cervix may be 
incised on either side within at the internal os with scissors or knife, after 
which the canal can be dilated or stretched enough to permit the intro- 
duction of the finger. Often this method of procedure is associated with 
an extensive laceration of the uterine structure into the parametrium. 
Furthermore, incision of the cervix is too radical an operation for mere 
exploration. It is only when it is necessary to institute treatment for 
a threatening condition within the uterine cavity that we would advise 
cervical incision, which should be through the vaginal portion. Another 



DISPLACEMENTS OF THE PELVIC ORGANS. 51I 

method of dilatation is that devised by Vulliet, which consists in packing 
the uterine cavity with pieces of gauze until the cervix becomes gradually 
dilated, and renewing this gauze packing until the uterine cavity is so 
well dilated that the finger can be introduced readily. This plan is open 
to the objections, however, that the gauze is an irritant, requires care that 
the patient does not become infected during the procedure, and in many 
cases, particularly when the cervix is the seat of inflammation and is a 
little rigid, the dilatation is ineffectually accomplished. 

The most effective method of dilating the cervix is accomplished by 
tents. These may consist of sponge, laminaria, or tupelo. Sponge tents 
are objectionable on account of the difficulty of rendering them sterile 
and because of the fact that they readily become impregnated with the 
discharges, which quickly decompose and predispose to infection. This 
danger has in some degree been obviated by the suggestion that the tent 
be covered with a rubber sleeve, but this requires the employment of 
special measures to convey the moisture to the tent. The laminaria tents 
are exceedingly effective, preferably the perforated ones. The tent should 
be carried into the uterine cavity without much force, the tent and the canal 
having been previously rendered, as near sterile as possible. As large a 
tent as can be introduced should be used. When the cavity is somewhat 
dilated or when the first tent is not sufficiently large, and more complete 
dilatation is desired, a number of tents or a nest can be used. More rapid 
dilatation is accomplished by moderately stretching the canal with bougies 
previously. If aseptic precautions are observed, the danger is not in- 
creased thereby. The details of the procedure and the precautions to be 
exercised have been given. (Sec. 56.) 

Treatment should be directed to the disorder which has caused the 
hemorrhage. It may not be convenient nor desirable to subject the 
patient to radical treatment, while the hemorrhage may be so severe as 
to necessitate the exercise of measures to save her life. For relief of 
hemorrhage various agents are advocated which exercise contractile 
power upon the involuntary uterine mucous membrane. Ergot is one 
of the most efficient. It not only causes contraction of the uterine 
muscle wall, but also decreases the amount of blood that is sent into the 
uterus through the contraction of the uterine vessels. Thyroid extract 
and the extract of mammary gland have been highly extolled. The 
various astringents are of benefit, as gallic and tannic acids; dilute sul- 
phuric acid; iron salts, especially the persulphate of iron; hamamelis; 
hydrastis and its salts, hydrastin and hydrastinin; and the tincture of 
cinnamon. The latter may be given with good effect in combination 
with either gallic or tannic acid, giving from ten to thirty grains of the acid 
with a tablespoonful of the liquid. Cotarnin hydrochlorate (stypticin), 
gr. ss — j every two or three hours, is frequently very effective in con- 
trolling hemorrhage. The administration of glonoin or the nitrate salts 
to decrease vascular tension are worthy of consideration. Perchloride of 
iron solution may be applied to the uterine cavity by injecting a few 
drops, or swabbing the cavity with it. 

The patient should be kept perfectly quiet in bed; if hemorrhage is 



512 GYNECOLOGY. 

severe, she should be prevented from rising even to evacuate the bowels 
or to void the urine. Cold applications may be made to the abdomen, 
and heat or a mustard-plaster applied between the shoulders, in order to 
divert the current of blood from the pelvis. Local applications of various 
astringents, such as alum, zinc sulphate, hydrastis, or hamamelis, used in 
strong solution or as a douche, may be used. Douches of hot water 
should be given the patient while in the recumbent position, using water 
at from iio° to 115° F., even 120° F. if the patient can bear it. The ob- 
jection to the injection is that the uterine cavity will contract upon its 
contents, causing contraction of the cervix, by which the contents maybe 
forced from the uterine cavity into the tubes, and produce inflammation 
within them, or, worse, a localized peritonitis. Gersterberg uses a strong 
solution of formol upon a cotton-wrapped applicator. A solution of 
aluminium acetate has been advocated. When hemorrhage is severe, 
endangering the patient by its continuance, the uterine cavity should be 
tamponed, by packing a good-sized piece of gauze firmly into the cervix. 
The further discharge of blood is prevented and dilatation of the canal 
facilitated when it can be explored with the finger. These measures for 
the treatment of hemorrhage are merely palliative. They do not correct 
the fault nor the trouble which induced it; and the earlier radical treat- 
ment can be instituted, the better it is for the patient and the more readily 
is the condition controlled. Slight bleeding from the vulva and vagina is 
readily controlled by making applications of an astringent- or a styptic, 
such as persulphate of iron directly to the diseased surface. The cavity 
should be packed, in order to secure further improvement through pres- 
sure. When bleeding occurs from an injury to the vulva, the most efficient 
method is to enlarge the external injury and secure the bleeding vessel 
by ligation. When a large surface bleeds, the hemorrhage is best con- 
trolled by packing with iodoform gauze, making firm pressure upon or 
into the wound. When the bleeding is the result of incomplete abortion 
or the existence of an intra-uterine growth, the offending cause should 
be removed. An interstitial endometritis should indicate the em- 
ployment of the curet. Atmocausis, or the application of steam to the 
uterine cavity by a special apparatus, has had many advocates, but it 
would seem desirable to employ more controllable measures, as it is im- 
possible to regulate accurately the amount of destruction to which the 
uterine mucosa will be subjected, and to equalize its distribution 
definitely. 

271. Vulvar hematoma, hematocele or thrombus are terms 
applied to hemorrhage which takes place in the tissues of the vulva. 
It arises as a result of injury sufficient to cause rupture of a vessel without 
a break in the integument. When the injury involves the bulb of the 
vestibule, hemorrhage may be extensive and cause a large-sized tumor, 
which involves one or the other large labium. Hemorrhage also occurs 
from rupture of varicose veins or from compression of vessels during the 
progress of labor. The latter is the most frequent cause. The tumor 
may attain the size of an orange or even of the fist, and may be very 
tense and painful. It usually occurs suddenly, and is associated with 



DISPLACEMENTS OF THE PELVIC ORGANS. 513 

more or less burning and pain in the region of the swelling while it develops. 
When the skin is unbroken and the collection does not become infected, 
it may be completely absorbed. 

272. Vaginal hematoma or thrombus uncomplicated is of rare 
occurrence. It is usually associated with hemorrhage into the vulvar 
tissue, forming a vulvovaginal thrombus. Generally it occurs upon one 
side of the vagina, and most frequently is a result of injuries sustained 
during labor. The exciting agent is the passage of the presenting part 
of the child, which frequently pulls off and stretches the vaginal attach- 
ments. This causes rupture of the vessels and severe bleeding. The 
tumor may attain a very large size, compress the vagina and rectum, and 
cause difl&culty in micturition. The physician may be in doubt, when called 
to see such a patient, whether it is an accumulation of blood or a suppura- 
tive process. The better plan of procedure is, of course, to make a care- 
ful examination. With the history of the patient in mind, we may be 
able to eliminate the probability of inflammation, especially shortly after 
a confinement. During the year 1898, three weeks after her first confine- 
ment, I saw a patient, thirty-four years of age, who had passed through 
a normal labor. She had, however, sustained a slight laceration of the 
perineum, which was repaired. Two weeks subsequent to her delivery 
she developed some elevation of temperature, with more or less distress in 
the pelvis. Examination disclosed a large swelling which compressed the 
vagina and rectum. The mass thus formed was quile large and pro- 
truded into the vagina to such a degree as to obstruct it greatly, as well as 
to encroach upon the rectum. Sensation of fluctuation was indistinct. 
The right buttock was edematous and so much more prominent than 
the left and the sensation of elasticity, almost fluctuation, so marked that 
I decided to incise through it and thus reach the mass, rather than to make 
an incision from the vagina. The incision into the buttock, however, 
disclosed that the swelling in it was entirely edematous. Through this 
incision the levator ani muscle was opened, when there was at once a 
discharge of a large quantity of bloody fluid and clots. By pressure 
through the vagina the mass was readily removed, and the patient looked 
and expressed herself as feeling greatly improved. A gauze wick was 
passed through the wound into this cavity with a view to insure drainage 
and to prevent its premature closing. The gauze was removed at the 
end of twenty-four hours, and the subsequent progress of the patient 
was uninterrupted. I saw another case of this kind in a young woman 
who had been delivered by forceps. The right side of the pelvis was 
apparently occupied by a large clot, which bulged into the vagina, pro- 
truded into the labium, and gave rise to suggillation of the entire buttock. 
This mass was incised from the vagina and was found to extend into the 
broad ligament of the right side. The clot was thoroughly turned out 
and the cavity packed with a large quantity of iodoform gauze. The 
patient recovered. I have observed one case of vaginal hematocele in 
. which labor was complicated by an ovarian dermoid. The union of 
this growth with the uterus had been destroyed by previous torsion. 
The tumor subsequently became engrafted by a broad band of adhesion 

33 



514 GYNECOLOGY. 

upon the omentum, from which it evidently received its nutrition. The 
tumor was attached below by folds of the peritoneum, which extended 
over and to the left of the bladder. In the fold, dipping down into the 
pelvis in front of the bladder and to the left of the vagina was an exten- 
sive collection of clotted blood, which had evidently been produced by 
pressure upon the inferior attachments of the tumor during the progress 
of labor. 

Diagnosis. Vulvar hematoma is apt to be confounded with edema 
of the labium and with labial tumors. Its development, however, is 
too sudden for the latter condition. Edema of the labium generally is 
associated with other disorders. It is not one-sided. Both labia are 
involved unless the edema is due to some special cause in which there is 
obstruction of vessels or lymphatics on one side only. Vulvar and vaginal 
thrombi are usually associated, producing the condition already described 
as vulvovaginal thrombus. The condition generally follows difficult 
or complicated labors. Pus-collections are rarely found in the lateral 
walls of the vagina, but are most frequently pushed into the vagina from 
the posterior fornix. Thrombi, on the other hand, are frequently found 
upon the lateral surface and rarely affect the posterior vaginal wall. 

Treatment. The amount of bleeding in these thrombi is usually 
limited, for the pressure of the tissues into which bleeding occurs naturally 
controls it. In non-infected cases the extravasated mass ultimately is 
absorbed, although in large collections it may remain for quite a long 
time. A patient came under my observation for pelvic inflammation. 
Examination disclosed posterior to the rectum, in the neighborhood of 
the sacrococcygeal articulation, a mass which had an elastic sensation. 
Upon inquiry, I found her first labor had occurred six months before, 
with a history of an injury to the coccyx. The coccygeal injury had, 
however, disappeared; the mass remained. As I had already made an 
incision through the vagina into the peritoneal cavity, I did not care 
to attempt to open into this from the vagina, on account of the dissection 
required around the rectum. An incision was made into the sac posterior 
to the anus, when a teacupful of thick, pasty, reddish material , evidently 
the remnants of a clot, was evacuated. Gauze drainage was instituted, 
and the cavity gradually closed. When the collection is small, it may, 
without detriment to the patient, be left to nature; but when large, the 
pressure produces thinning of the enveloping wall and permits the 
ready introduction of infecting germs, either from the rectum or vagina. 
In such collections the danger of subsequent infection is decreased by 
free incision and the evacuation of the accumulation. Not only, should 
the clots be removed, but measures must be employed to preclude further 
hemorrhage. A large bleeding vessel may be secured by passing a 
ligature beneath or about it with a needle. When ligation is impracticable 
hemorrhage should be controlled by packing with iodoform gauze. The 
gauze should be retained for two or three days, and should be renewed 
with a smaller amount, in order to keep the external wound open long 
enough for the cavity to undergo thorough contraction. 

273. Peri-uterine hemorrhage may be intraperitoneal or extra- 



DISPLACEMENTS OF THE PELVIC ORGANS. 515 

peritoneal. Intraperitoneal hemorrhage, unless preceded by inflammatory 
adhesions which form limitations, is free, and may be large in quantity. 
Extraperitoneal hemorrhage takes place into the cellular tissue about the 
uterus and the broad ligaments, and is limited by the pressure of the tissue. 
Hemorrhage into the cellular tissue beneath the peritoneum undergoes 
coagulation and forms a bloody tumor, known as a hematocele. It is 
analogous to the thrombus which occurs during the progress of labor, 
and which we have described under the term \ailvo vaginal. 

Hemorrhage into the peritoneal cavity will form a coagulum, and sub- 
sequently a tumor; or, when very free, may remain liquid and the hemor- 
rhage continue until the death of the patient or until surgical intervention 
is practised. 

The causes may be divided into two classes : i . Hemorrhage that results 
from extra-uterine pregnancy, which is more important, because more 
frequent and more serious in its results; 2. Hemorrhage of nonpuerperal 
origin, which occurs without the existence of fecundation. The pelvis 
being the most dependent portion of the abdomen, hemorrhage from any 
of the intra-abdominal viscera, or within any portion of the peritoneal 
cavity, naturally gravitates into the pelvis. Thus, we may have intra- 
abdominal hemorrhage from traumatic injuries of the liver or spleen,. 
rupture of an aneurysm of the aorta or of the celiac axis, rupture of 
varicose veins, from the ovary, regurgitation from the Fallopian tube of 
menstrual blood (particularly when there is obstruction of the uterine 
neck), rupture of a uterine or tubal collection, rupture of bands of ad- 
hesion in the pelvic peritoneum, slipping of a ligature, or the retraction of 
a cut vessel following an operation. Any of these causes may lead to an 
accumulation of blood in the pelvis — particularly in Douglas' pouch 
— whereby the intestines containing gas are floated up and the uterus 
is pushed forward. Sooner or later the coagulated blood causes irritation 
and leads to the formation of adhesions, by which the collection may be- 
come encysted and form what is known as an intraperitoneal hemato- 
cele. (Fig. 448.) The most frequent cause, however, belongs to the 
division of the puerperal or extra-uterine. 

Symptoms. Intra-abdominal hemorrhage from whatever site or 
cause, unless limited by previous adhesions, wfll gravitate into the pelvis. 
The gravity of the symptoms will depend upon the size of the vessels in- 
jured and the rapidity of the hemorrhage. Generally the rupture of the 
vessel is associated with pain in the vicinity of the lesion. This sensation 
may be intense cuttmg or burning. If the hemorrhage is slight, it may 
be slow and produce little constitutional evidence if any. When severe, 
the symptoms of shock are profound and may be announced by agonizing 
pain, accompanied by syncope or repeated attacks of fainting. The 
skin is pale, covered with a cold, clammy perspiration, the pupils are 
widely dilated, pulse feeble, frequent, or absent in the radius. The mere 
effort to raise the head may lead to unconsciousness. The temperature 
is subnormal. The syncope may be associated with such reduced arterial 
tension that a clot is formed, which obstructs the bleeding vessel and be- 
comes so firmly fixed that as the patient reacts the hemorrhage is con- 



5i6 



GYNECOLOGY. 



trolled. The salts of the blood so irritate the peritoneum that a mild 
grade of peritonitis results, which leads to the collection becoming en- 
cysted. The watery portions of the blood are absorbed and the clot 
may gradually become organized and result in thickening of the peri- 
toneum and adhesions as the only traces of its occurrence. More fre- 
quently the condition from which it has originated, or the stagnation 
from the imprisoned intestinal coils, or previously existing tubal disease, 
leads to infection and the formation of a pelvic abscess. Unless such a 
condition is promptly evacuated, general infection may follow. 




Fig. 448. — Intraperitoneal Hemorrhage. 



274. Extraperitoneal hematocele may be produced by puerperal 
or nonpuerperal causes. (Fig. 449.) It is more frequently associated 
with ectopic gestation. The nonpuerperal causes are the rupture into 
the broad ligament of varicose veins, and injury of an artery or its retrac- 
tion from the stump when the pedicle is ligated en masse. 

Symptoms. Extraperitoneal hematocele in the broad ligament is 
limited in its character, and causes symptoms similar to those which have 
already been enumerated for the intraperitoneal variety, though in a much 
slighter degree. The indications of shock and collapse are much less 
marked, and hemorrhage, from its limitation, is much less serious in its 
influence. As it occupies the broad ligament, it is usually situated upon 
one side of the pelvis, and pushes the uterus to the opposite side. This 
hemorrhage may be situated either in the upper part or in the base of the 
broad ligament, and may produce different physical signs according to 
its situation. The hemorrhage, when low in the broad ligament, may 
dissect forward between the uterus and bladder, or backward around 
the uterus beneath the peritoneum, and extend to the opposite side. In 



DISPLACEMENTS OF THE PELVIC ORGANS. 



517 



the great majority of cases, however, extraperitoneal hemorrhage is one- 
sided. 

Diagnosis. Peri-uterine hemorrhage, whether intraperitoneal or 
extraperitoneal, is determined by the phenomena of internal hemorrhage. 
It is true that similar symptoms — a sharp pain, symptoms of collapse — • 
might arise from rupture of a pyosalpinx or a pelvic abscess. In such 
accidents, however, acute agonizing pain is caused, with symptoms 
of peritoneal reaction which are more intense, but a tumor does not form. 
A retrofiexed gravid uterus may be mistaken for hematocele, but the 
outline of the boundaries of the organ are more definite. In hematocele 
the uterus is frequently inclosed within a mass or pushed forward, while 




Fig. 449. — ^Extraperitoneal Hematoma. 

by a careful examination in a retrofiexed gravid uterus the cervix is found 
at a higher level, either in the axis of the vagina or looking forward. 
A distinct angle exists between it and the smooth, definitely outlined mass 
filling up the pelvis, which should not be confounded with hematocele. 
Ovarian cysts and uterine fibroids imprisoned within the pelvis possess 
nothing in common with hematocele. The manner of appearance and 
the course of development of the condition are entirely different. Extra- 
uterine pregnancy before rupture does not present similar symptoms, 
although it may be a starting-point for the later hemorrhage, and unless 
the examination is carefully performed, rupture may result from the 
methods used for diagnosis. Extraperitoneal is determined from 
intraperitoneal hemorrhage by the situation of the collection upon one 
side, which is more definitely localized, its boundaries more sharply 
defined, and the uterus generally pushed to the opposite side, while in the 



5l8 GYNECOLOGY. 

intraperitoneal hematocele the latter is surrounded by the accumulation 
or is pushed forward. It is not always easy to determine the cause of the 
hemorrhage. Previous symptoms of pregnancy, amenorrhea, with 
symptoms rapidly ushered in, profound depression, and very marked 
anemia, should lead to the suspicion of probable rupture of a fetal sac. 
Symptoms of collapse or depression, or internal hemorrhage, may arise 
from rupture of internal varicose veins. In hemorrhagic salpingitis 
the condition is more insidious, the progress more slight, owing to the 
gradual effusion of blood. Should there be any doubt of intraperitoneal 
hemorrhage, the true condition can be surely determined by making 
an exploratory puncture through the posterior vaginal fornix. This is 
a justifiable and commendable procedure. 

Prognosis. The affection is always a serious one. We cannot be 
certain that death may not result suddenly from a continuation of the 
hemorrhage, or, when hemorrhage has apparently been arrested, that the 
clot may not be loosened and hemorrhage again recur. In large col- 
lections the progress of the case is exceedingly tedious. Plastic material 
remains about the uterus for a long time, becomes more or less organized, 
frequently is a source of discomfort, and often a cause of sterility. That 
sterility is not invariably caused is evident from the numerous cases 
recorded of women who have suffered from hematocele where the collec- 
tion is ultimately absorbed, the patient has an ectopic gestation later. 
The presence of a large collection of blood within the pelvis is a source 
of continuous danger from its close proximity to the vagina and rectum, 
through either of which channels infectious material may enter and 
cause pelvic suppuration. Suppuration is particularly apt to occur 
if the individual has had previous tubal disease. Doubtless, the infection 
develops from this. 

The extraperitoneal variety is less serious in its influence, more likely 
to undergo absorption, and leaves less evidence of its previous existence. 
Its situation renders it less susceptible to infective changes. When the 
collection is large, however, and has existed for some time, the patient 
will, without question, have a more favorable prognosis by the exercise 
of measures for its removal. 

Treatment. Active interference must depend very much upon the 
character of the symptoms and the severity of the attack. When the 
symptoms are such as to indicate escape of a large quantity of blood into 
the pelvis, the abdomen should be opened promptly, clots removed, 
and the bleeding vessel secured. In profuse internal hemorrhage liga- 
tion of the bleeding vessel is just as certainly indicated as in hemor- 
rhage from the radial or femoral artery. When hemorrhage has appar- 
ently been arrested and a reactive peritonitis develops, we are not abso- 
lutely certain that the clot cannot be displaced and the patient suffer 
from a recurrence of hemorrhage, which may be fatal; or that the collec- 
tion of fluid about which nature is forming its barriers may not become 
infected from the neighboring hollow viscera and cause subsequent 
changes, necessitating its evacuation, with increased danger to the patient. 

In extraperitoneal hemorrhage the indications for operation are not 



DISPLACEMENTS OF THE PELVIC ORGANS. 519 

SO marked. The symptoms are much slighter, the amount of exudation 
is less, and the probabilities of infection are diminished. In such cases 
we can afford to wait and trust to nature to absorb the effused fluid. 
In large collections, however, much time will be saved by evacuation. 
The method of operative procedure will depend upon the time the patient 
comes under observation. In an acute attack, with an evidently bleeding 
vessel, we should follow the procedure which affords the most accurate 
and complete exposure, with ready access to the field of hemorrhage. 
Abdominal incision meets every indication, as through it we are enabled 
to see and to reach the bleeding vessel. If the patient comes under 
observation a week or more subsequent to the hemorrhage, when the 
peritoneal reactive processes have encysted the collection, and vaginal 
and abdominal palpation discloses that barriers have been formed by plastic 
exudate between the knuckles of intestine over the surface of the hema- 
tocele, the vaginal incision is preferable. This procedure respects the 
barriers which nature has constructed to limit the collection, and affords 
free opportunity for the evacuation of clots. They are removed by the 
finger and by irrigation. With gauze packing and a free vaginal incision 
the subsequent progress of the case is much less severe and the length 
of the convalescence decreased. When blood has been effused into the 
peritoneal cavity and clots have formed, by neither the abdominal nor 
the vaginal method would we be able to remove all the clotted blood. 
The clotted material remains adherent to the sides of the sac and pelvis, 
and is likely in either procedure to cause a certain elevation of tempera- 
ture as a result of the fermentation taking place in the retained fibrin. 
When the condition has gone on to suppuration and is accessible, the 
vaginal route is beyond question the preferable procedure for reaching 
the collection. I would not be understood as teaching that all cases of 
internal hemorrhage are necessarily fatal or require operative interfer- 
ence. If the patient is unwilling to undergo operation, or the conditions 
do not urgently demand it, the promotion of absorption should be accom- 
plished by keeping her absolutely at rest in bed, by the use of the catheter 
to empty the bladder, and by the evacuation of the bowels or intestines 
by enemas. Absolutely interdict the use of opium, keep the vagina 
antiseptic by repeated douches, and when it is supposed that hemorrhage 
still continues, or is in danger of being renewed, apply an ice-bag over the 
abdomen, introduce ice suppositories into the rectum, and thus bring the 
cold in close contact with the bleeding vessels. In extraperitoneal hem- 
orrhage indications for operation are much less marked. The absorption 
may be promoted by keeping the bowels regular and the patient at rest, 
and by the application of cold or of counterirritants over the abdomen. 
When operative interference seems indicated, the preferable procedure 
is to make an incision through the vagina into the broad ligament, tear 
with the finger or a blunt instrument through the tissue of the ligament 
until the hematocele is reached, then enlarge the opening, turn out the 
clots, irrigate the cavity, and introduce gauze to afford vent for further 
discharge. When the collection is very large, it may sometimes be 
evacuated by an incision above Poupart's ligament. Pushing back 



520 GYNECOLOGY. 

the peritoneum, the collection is exposed, opened and evacuated. After 
the cavity is thoroughly emptied, it should be packed with gauze, as 
already advised. 

ECTOPIC GESTATION. 

275. Ectopic Gestation. When the fecundated ovum does not 
reach its normal situation— the uterine cavity — but undergoes develop- 
ment external to it, the condition is known as ectopic gestation or extra- 
uterine pregnancy. The former term is the better as it signifies misplaced. 
While the ovum may develop in the uterine wall and present the most 
dangerous form of misplaced pregnancy, it still is not properly described 
as extra-uterine. 

Much difference of opinion exists as to the point at which the union 
of the spermatozoon and the ovum, and its consequent fecundation, take 
place. Tait very firmly asserted that in the normal condition this fecun- 
dation always occurred in the uterus. Others as emphatically believe 
that fecundation may occur at any point between the internal os and the 
exit of the ovum from the Graafian follicle. The recognition of the fact 
that in the lower animals the spermatozoa in normal conditions are 
found in contact with the ovary would seeni to afford justification for the 
belief that fecundation does not absolutely occur within the uterine cavity. 
Fecundation in the majority of cases undoubtedly occurs in the tube, but 
may take place at any point in the progress of the ovum to the uterus. 
The changes which follow, as a result of fecundation, produce altera- 
tions in the uterine mucosa which prepare it for the reception of the 
fecundated ovum. 

Causes. Much difference of opinion still exists as to the causes which 
lead to the occurrence of a misplaced gestation. Some would deny that 
inflammation has any part in its production, and would lead us to believe 
that the existence of inflammation in the tube always produces alterations 
which preclude the subsequent occurrence of pregnancy. Every abdom- 
inal surgeon of any experience, however, has seen cases in which well- 
marked tubal disease, and frequently of evident gonorrheal origin, has 
subsequently recovered, and the patients have given birth to children. 
During the active inflammation of such tubes the abdominal orifices are 
closed off by exudate, which subsequent to resolution, may be reabsorbed 
and afford an unobstructed entrance to the tube. Those who exclude 
inflammatory conditions as a cause attribute the occurrence of ectopic 
gestation to congenital conditions, consisting of long tortuous tubes con- 
taining numerous tubal constrictions, especially, or, a tubal diverticulum. 
It is also attributed to intratubular growths, which limit the caliber of the 
canal, or to growths in the tubal wall, or to pressure of growths external 
to the tube. The hypothesis of the migration of the ovum from the 
ovary of one side to the tube of the opposite side has been well established. 
As evidence, a history is recorded in which an intra-uterine pregnancy 
occurred in a woman who had lost the tube of one side and the ovary 
of the opposite side. It has been supposed that the ovum, having 



ECTOPIC GESTATION. $2 1 

become fecundated upon its emergence from the Graafian follicle, attains 
too great a size before it reaches the tube of the opposite side to permit 
of its passage down that canal. The vegetations upon the ovum, 
however, which form the chorion, do not develop until the ovum has come 
in contact with the tubal mucous membrane, hence this cause is of doubt- 
ful application. Every one familiar with poultry is aware that occasion- 
ally an unusually large egg will be laid. Indeed, I have seen cases in 
which the egg was too large to pass through the canal. It is not improb- 
able that similar conditions exist in the formation of the o^oim, and that, 
occasionally, an oversized fecundated ovum may lodge on its way to the 
uterus. Fright and emotional conditions at the time of conception are 
ascribed as causes. Were the latter, however, an important factor, 
tubal gestation would be likely to occur much more frequently in illegiti- 
mate cases. 

The study of the history of ectopic gestation long ago led to the rec- 
ognition that a misplaced gestation was frequently associated with 
prolonged sterility. It is not unreasonable to believe that a period of 
sterility has been one in which inflammatory conditions existed which 
have subsequently improved. Investigations of inflammatory conditions 
disclose the fact that loss of the tubal epithelium is of rare occurrence. 
The existence of the gestation is due, not so much to the presence of 
patches of desquamated epithelium, as to inflammatory changes which 
cause the canal to become narrowed, and the folds of the mucous membrane 
thickened, thus rendering the passage of the fecundated ovum more 
tedious than under normal conditions. The expedition of the ovum to 
the uterus is also retarded by the decreased peristalsis resulting from 
hyperplasia and loss of activity in the muscular wall. Gonorrheal in- 
flammation seems to have a special influence in the production of ectopic 
gestation. Thus, Prochownik found gonorrhea in three out of eight 
cases, and Ahlfeld, in the few cases he has observed, also attributes 
the condition to gonorrheal infection. Ectopic gestation may occur at 
any period of the reproductive life, whether in a first pregnancy or in 
women who have borne a number of children. Analysis of a large num- 
ber of cases will show that several years of previous sterility will occur in 
the majority of cases. It may occur in the first pregnancy of a woman 
who has been married eight, ten, or twenty years, in a woman who has 
not given birth to a child for five or six years; or, again, it may follow im- 
mediately after a labor or abortion. Furthermore, it may occur in the 
bride. Both tubes may be pregnant concurrently, one tube may contain 
a tubal pregnancy, or a tubal may complicate a uterine pregnancy. 
Cases have been reported in which there occurred a twin pregnancy in 
the outer portion of the tube, and an interstitial or single pregnancy in 
the uterine end, making three embryos in the one tube. Dr. Wilmer 
Krusen has reported a tubal pregnancy which had ruptured, and in 
the sac three fetuses were found. 

Varieties. Ectopic gestation is most frequently of the tubal variety. 
Some undisputed cases of ovarian pregnancy have been described, but 
when we consider the fecundated ovum and the conditions necessary for 



522 



GYNECOLOGY. 



its nutrition and development, it is evident that the ovum rarely 
develops when not in contact with the Miillerian mucous membrane. 
It is quite probable that many of the cases described as ovarian preg- 




FiG, 450. — Tubal Pregnancy. 

nancy have been originally tubo-ovarian and have become separated 
from their tubal relation. Tubal gestation occurs most frequently in 
the central portion of the tube. (Fig. 450.) It may be situated toward 




Fig. 451. — Tubo-ovarian Pregnancy. 

its abdominal end, and as it develops, is extruded or partly extruded 
and comes in contact with the ovary, when it is known as tubo-ovarian 
pregnancy. (Fig. 451.) When situated within the central portion of the 




Fig. 452. — Tubo-uterine or Interstitial Pregnancy. 

tube or ampulla, it is ampullar or tubal pregnancy. Toward the uterine 
end, or that portion which passes through the uterine wall, it is tubo- 
uterine or interstitial pregnancy. (Fig. 452.) Rupture of a tube with 



ECTOPIC GESTATION. 523 

partial escape of the ovum, which retains its placental attachment, may 
subsequently develop, when it becomes an abdominal pregnancy. Ab- 
dominal pregnancy generally is secondary and primary only in extremely 
rare instances. Dr. B. C. Hirst reports a case which seemed to be a 
primary abdominal pregnancy. The reimplantation of the ovum upon 
the peritoneal surface and its subsequent development have been asserted 
to be an impossibility, but when we find the tube having no longer any 
relation or connection with the sac, the placenta situated, as in the case 
of Tuholske, upon the liver, and apparently upon the folds above it, it 
seems impossible to explain its occurrence upon any other ground than 
that of reimplantation. 

Course and Progress. The fecundated ovum lodged in the tube 
finds a condition different from that of the ovum within the uterine cavity. 
In the latter, the mucous membrane consists of glandular or lymphoid 
tissue, which becomes thickened as a preparation for the reception of 
the fecundated ovum, in which the trophoblast cells of the ovum enable 
it to sink in and become embedded. The syncytial cells in the chorion 
arise from the trophoblast cells, and the uterine epithelium in no sense 
plays any part in their production. In the tube it meets with an entirely 
different condition. There are no glands, and there is much difference 




Fig. 453. — Tubal Abortion. 

of opinion as to the formation of the decidua. This, in the uterus, consists 
of a compact and spongy layer, but in the tube, of a compact layer only. 
The decidua cells are found not so much in immediate contact with the 
wall of the tube as at either end of the sac. Bandler, in his investigations 
on the development of ectopic gestation, divides it into three types: 
I, the columnar type of tubal gestation; 2, the intercolumnar; and 3, the 
centrifugal. 

I. In the columnar variety, at no point in the tube wall or in the 
mucosa is there any decidual change or any condition representing the 
trophoblast cells or villi, consequently no decidua nor trophospongia 
develops. The ovum is surrounded by mucous folds and only an inva- 
sion of the tubal capillaries follows. Abortion in these cases is easy and 
causes but little danger; bleeding occurs; the fetus dies, and further hem- 
orrhage expels it. The tube may subsequently become normal or a 
hematosalpinx may follow. (Fig. 453.) 2. In the intercolumnar type 



524 GYNECOLOGY. 

one-half of the tube is normal, the other torn and infiltrated. The 
mucous folds are involved down to the muscularis. The ovum is situ- 
ated upon the tube wall, where it compresses and destroys the folds at 
the situation known as the serotina. These folds are united at either 
side about the ovum, forming a pseudoreflexa. Some distance on either 
side of the serotina, tissue resembling decidua, with closely grouped 
cells without capillaries or spaces, rests upon and invades the free surfaces. 
The invasion traverses the mucosa in irregular branches or projections 
about the blood-vessels, invading and infiltrating their muscular walls 
up to and into the lumen. Trophoblast cells are accompanied by syncy- 
tium, but at no point do the connective tissue cells, the tubal folds, 
or the delicate submucosa, if present, exhibit any evidence of change 
which resembles in the slightest degree those occurring in the uterine 
mucosa, from which any decidual cells develop. Neither is there at 
any point any change of a so-called syncytial character. The ovum 
rests upon the wall, and the tubal fold immediately beneath it will be 
compressed, but the epithelium may remain in the depressions. Other 
folds may form a capsularis, which consists of mucosa alone. An inter- 
villous space may develop when the capsularis is formed. The villi at 
the placental site enter the wall and the hemorrhage follows, especially 
upon the invasion of vessels of the capsularis by fetal cells. The preg- 
nancy may terminate in abortion, complete or incomplete, the latter being 
the rule usually. If the abdominal end is closed, a hematosalpinx or 
tubal mole may follow. 

3. In the syncytial type the tissue of the tube is invaded by villi cell 
groups — syncytial cells. Here again there is no evidence of a decidua 
or of any decidual reaction. When uninterrupted, the capsularis unites 
with the mucosa of the enveloping tube wall in the same way that this 
process is exemplified in the uterus. The centrifugal ovum sinks into 
the wall of the tube, when invasion of the wall and vessels by the villi 
occurs. Rupture may take place at the summit or hemorrhage from 
invasion of the vessels entering the intervillous spaces. Bleeding from 
the villi penetrates the serosa and rupture at the placental site may follow, 
or, we may have multiple perforations and erosions. The ovum apparently 
eats up the tube wall and its destruction is not the result of pressure. 
In such cases the perforations may be so minute as to be revealed only 
by a microscope. The death of the ovum may not arrest the growth 
of the villi. This form furnishes the majority of cases of rupture. Very 
frequently the hemorrhage is due not to rupture but to the erosions from 
the perforating villi. The presence within the tube of the developing 
ovum causes the entire structure to become turgid and vascular. There 
is some tendency in the tube to the development and extension of its 
structure, but to a much less degree than in the uterus. The wall becomes 
stretched and attenuated, and thin. The mucous membrane is stretched 
and its folds effaced. As the tubes vary in length and thickness, the 
rapidity of thinning differs correspondingly. When the ovum is situated 
in the outer third, changes follow in the ostium. In the first four cases 
the fimbria are swollen, turgid, and the congestion extends to the adjacent 



ECTOPIC GESTATION. 525 

muscular and serous tissue; the fimbria are gradually retracted, while 
the peritoneal margin of the ostium forms an irregular ring, which in 
four and one-half weeks projects beyond the ends of the fimbria. It 
finally contracts, and at the end of the eighth week is completely contracted 
and hermetically sealed. The occlusion, however, is not constant. 
Occasionally the ostium dilates. The nearer the ovum is situated to 
the abdominal end, the less likely is it to close. As the tube distends, 
its vessels rupture and hemorrhage takes place, which fills up the sac and 
may cause the extrusion of the ovum. The more firmly the tubal end 
becomes occluded, the greater the danger of tubal rupture. Its situa- 
tion near the abdominal ostium favors its extrusion through the opening 
into the abdomen as a tubal abortion. Moles occur in tubal as in uterine 
gestation; indeed, they are more frequent in the former. They vary 
from one to eight centimeters in diameter and are globular or ovoid, 
assuming the jatter shape in the larger varieties. The tubal moles are 
formed by hemorrhage, which occurs in the subchorionic diameter, 
between the chorion and the amnion. This hemorrhage may be gradual 
or sudden and results in the death of the embryo — often in its disappear- 
ance. Its origin in a misplaced pregnancy in the absence of any vestige 
of the fetus is recognized by the discovery, through the microscope, of 
the chorionic villi. The outer investing membrane, the chorion, is gen- 
erally shaggy, with villi, which are rendered more visible by washing the 
clot under a gentle stream of water. When the amniotic cavity is oblit- 
erated, doubt may exist as to the character of the mass, but section will 
disclose the villi in clusters as small circular bodies. 

Tubal abortion has been mentioned as one of the terminations of 
tubal gestation, when the developing embryo occupies the external third 
of the tube. The nearer the fecundated ovum is situated to the ostium, 
the greater the danger of its extrusion. As the embryonal sac in- 
creases to a size beyond that which the tube is able to accommodate, it is 
pushed out through the funnel shaped cavity and escapes into the abdo- 
men. This accident is denominated tubal abortion, and frequently is as- 
sociated with profuse hemorrhage, similar to that which occurs in uterine 
abortion. The mole is discharged with copious hemorrhage into the 
peritoneal cavity. This displacement is likely to take place during the 
first two months of the pregnancy. When the ostium is closed, blood 
escapes from the tube only after rupture of the sac. The quantity of 
blood discharged sometimes is enormous and attended with all the 
symptoms of internal hemorrhage. This condition is one of the most 
frequent causes of pelvic hematocele. Internal hemorrhage in such 
cases had been ascribed to metrorrhagia, to reflex menstrual dis- 
charge from the uterus, or to hemorrhage from the Fallopian tube. 
The reason why it has been associated with metrorrhagia is that while 
the embryo is developing in the tube, a decidua is forming in the 
uterus. With a tubal abortion, hemorrhage occurs from the uterus as 
a result of the separation and the expulsion of this decidua. 
As this frequently happens near the time when the patient expects to 
menstruate, it consequently is regarded as a reflux menstrual fluid. Fre- 



526 GYNECOLOGY. 

quently the bloody discharge from the uterus may be derived from a 
gravid tube in protracted tubal abortion. If the bleeding occurs at a 
time not synchronous with the menstrual flow, it often is attributed to a 
disorder of the uterus. In all such cases the affected tube and the bloody 
discharge should be examined carefully for the presence of the embryo 
in the chorionic villi. The abortion may be complete or incomplete — 
complete when the embryo and its envelope are discharged; incomplete 
when a portion remains attached to the tube. The latter is more com- 
mon. The danger is increased in these cases owing to the fact that the 
bleeding is apt to recur while the mole is retained. The villi will be dis- 
closed by a careful microscopic examination of the extruded mass. 
They are discovered in sections of the adherent pole of the mass. 

The most frequent termination of tubal gestation is that of rupture. 
As the embryo develops, the tube becomes more and more thinned, until 
it is no longer able to resist the inward pressure, and rupture results. 
Rupture of the gestation sac may be considered under: i. Primary 
rupture; 2. Secondary rupture — each of which may be intraperitoneal 
or extraperitoneal. 

I. Primary rupture may take place at any time between the third 
and tenth weeks after impregnation. It rarely is deferred beyond the 
twelfth. Predisposing causes of rupture are the gradual thinning of the 
gestation sac by the growth of the ovum or the undue distention of the 
membrane by hemorrhage, especially at the seat of implantation of the 
chorionic villi. The perforation of the tubal wall by the villi may be 
excited by such violence as jumping from a train, straining at stool, 
jarring of a carriage, vomiting or sexual congress. Rupture may occur 
as a result of efforts to determine the diagnosis. 

It was my misfortune to see a case of this kind in which the examina- 
tion by me and subsequently by the attending physician was followed 
within a few minutes by symptoms of profound collapse. This confirmed 
the suspicion that an extra-uterine pregnancy was present. As soon as 
permission could be secured, the abdomen was opened and half a gallon 
of liquid blood was found within it. Although the vessel was secured, 
and every measure was taken to restore the patient she succumbed to the 
shock. 

The tube is enveloped in two-thirds of its circumference by the per- 
itoneum which forms a mesosalpinx. As the tube is enlarged by the 
developing embryo the mesosalpinx separates. This condition is true 
only of the internal two-thirds of the tube. The external third is not 
supplied with the mesosalpinx. The intraperitoneal rupture is three 
times as frequent as the extraperitoneal. In primary intraperitoneal 
rupture the embryo and its enveloping membranes, or a mole, are dis- 
charged into the abdominal cavity, and a certain amount of hemorrhage 
follows. The amount of blood extravasation will depend upon the 
period of pregnancy when the rupture occurs. When early, it may be slight. 
However, after the first month, it is copious — frequently sufficiently so 
to cause death in a few hours. I saw one patient who had missed her 
period but five days. She was taken with a violent pain at night, fainted 



ECTOPIC GESTATION. 5^7 

several times, and was seen and subjected to operation the following 
morning. She was then extremely anemic and the abdomen was found 
to be filled with a large quantity of blood which had escaped from a cyst not 
larger than a bean, in the left Fallopian tube. The ligation of the bleeding 
vessel and the removal of the extravasated blood resulted in her restora- 
tion to health. Frequently the hemorrhage may be so great as to cause 
death in a few hours — even half an hour. When a rupture is deferred 
until the seventh week, the embryo or mole is not discharged constantly 
through the opening. The quantity of blood which escapes may be large, 
and demand immediate attention, or it may be slight in character, per- 
mitting the patient to escape the immediate dangers incident to the ac- 
cident with slight shock. The effused blood may be absorbed and re- 
covery ensue. When the discharge is not excessive, the blood collects 
in the rectovaginal fossa and floats the coils of intestine, forming an intra- 
peritoneal hematocele as has been described. 

Dangers of the intraperitoneal rupture are: i. Hemorrhage so great 
as to cause immediate death; 2. The fatal result may be caused by re- 
peated hemorrhage. In primary extraperitoneal rupture that portion 
of the tube not covered by peritoneum gives way and permits the discharge 
of the ovum and the accompanying blood between the layers of the meso- 
salpinx. Here the blood is forced into the connective tissue between the 
layers of the broad ligament, and, fortunately for the patient, the bleeding 
is checked by the pressure from the resisting tissues. Generally it is 
arrested before it assumes dangerous proportions. This lesion rarely 
causes trouble. Occasionally the rupture of the tube is slight, the embryo 
escapes partly, with its membranes remaining uninjured, and the preg- 
nancy will continue. Rupture affords increased space for further devel- 
opment, and, the power of resistance being decreased, the ovum, as it 
increases in size, burrows between the layers of the broad ligament. 
The rupture may be gradual; the tube does not split suddenly, but, as its 
walls, through the gradual distention, become thinned, they yield in the part 
uncovered by peritoneum, until an opening forms and the ovum is ex- 
truded, accompanied by sudden hemorrhage. The extent of collapse 
and its duration will depend largely upon the amount of blood effused. 
The artificial opening gradually extends, the embryo and placenta make 
their way into the new area, and, unless the hemorrhage is sufficient to 
terminate the life of the embryo, the pregnancy is continued. This is 
known as a mesometric or an intraligamentary gestation. In this anoma- 
lous development of the ovum the placenta is liable to many changes which 
will influence the life of the fetus and the mother vitally. The tubal 
mucous membrane plays a very insignificant part in the formation of 
the placenta. The latter is developed mainly from the fetal tissues, as 
the tube does not develop a decidua. With the fecundation of the ovum 
there are at once developed changes in the uterine mucosa in preparation 
for its retention and sustenance. When the fecundated ovum is arrested 
in its progress and prevented from entering the uterus, the uterine de- 
cidua continues to develop as if the ovum were normally placed. This 
decidua, however, rarely is retained until the completion of gestation, 



528 GYNECOLOGY. 

but is thrown off during a false labor — frequently when the patient suffers 
from symptoms of tubal abortion or tubal rupture. The occurrence of 
this profuse bleeding after one or two months' amenorrhea, with the dis- 
charge of a cast or shreds of tissue from the uterus, which frequently may 
be enveloped by a large clot, leads the patient and her attendant to be- 
lieve that a uterine abortion has occurred. When the patient goes to 
term, the uterine decidua is thrown off as a cast or in shreds during the 
early months of pregnancy. When the decidua is discharged in small 
fragments, this takes place without unusual pain; but en masse, the symp- 
toms are similar to those of a miscarriage. The absence of the uterine 
decidua at the death of the ovum from rupture of the cysts, even in the 
early stages of pregnancy, is no proof that the membrane has not existed 




Fig. 454. — Complete Rupture of a Tubal Sac. 

and been expelled before fetal death. When pregnancy occurs in one- 
half of a bicornate uterus, the decidua is present in the unimpregnated 
cornu. Under no circumstances, however, either in the normal or ab- 
normal pregnancy, is a decidua found in the Fallopian tubes. As the 
destructive changes of the mucous membrane of the genital tract associated 
with menstruation are limited to the uterine cavity, so the true decidua 
is found in the same portion. It is sometimes important to avoid con- 
founding the decidua of pregnancy with the cast thrown off from the 
uterus in membranous dysmenorrhea. In the former it consists of a 
compact layer of decidual cells. In the latter, the cast is more likely to 
involve a portion of the glandular structure of the uterus. 

Rupture may be complete or incomplete. Complete rupture is 
one in which the ovum and its envelopes escape, either into the peritoneal 
cavity or into the broad ligament, with more or less profuse hemorrhage. 
(Fig. 454.) A partial rupture may result in the gradual thinning of the 
wall until it gives way in one place. When this takes place extraperitone- 



ECTOPIC GESTATION. 529 

ally, it is reinforced by plastic exudate, with the occurrence of little hem- 
orrhage, if any. (Fig. 455.) Successive ruptures or partial ruptures 
thus occur until finally the envelope becomes sufficiently distended to 
permit the fetus to develop as in an intra-abdominal pregnancy. 

At no time during such a rupture has the separation occurred between 
the placenta and the tube. In the extraperitoneal variety the embryo 
and placenta gradually occupy a sac formed by the expanded tube and 
separated layers of the broad ligament. The floor of this space is formed 
by connective tissue and the levator ani muscle. The ultimate effects 
depend to a great extent upon the original situation of the placenta. 
When the embryo is situated above the placenta, the latter is depressed 
between the layers of the broad ligament, until it is arrested by the pelvic 
floor. If the embryo lies below, and the membranes burrow between 
the layers of the broad ligament, the placenta is pushed up until it lies 
high in the abdomen. As there is no tubal decidua, the placental villi 
lie embedded in the decidual cells without any intervillous system exist- 




FiG, 455. — Incomplete Rupture of Gestation Sac. 

ing. When the placenta is displaced into the tissues of the broad liga- 
ment, which occurs gradually, its structure becomes seriously damaged. 
The villi are less perfect in their contour, points of extravasation of blood 
are present, and blood-crystals are abundant. Finally, under the pres- 
sure, the placenta becomes gradually reduced to a mass of compressed 
villi; its serotina is destroyed and is replaced by blood-crystals and by 
organized blood-clot. While the consequences to the placenta from its 
displacement into the tissue of the broad ligament are thus marked, it 
is not attended with nearly so much danger as when the placenta is situ- 
ated above the embryo. It is then subject to extreme disorganization, 
forming, as it does, the roof of the gestation sac. The changes that take 
place in the placenta, owing to the pressure of the developing fetus, 
have a great influence on the subsequent history of the pregnancy, in a 
marked degree imperilling the life of the mother. They are, in the 
majority of cases, disastrous to life in the fetus. The constant tension 
to which the peritoneum covering the gestation sac is subjected leads 
to partial detachment of the placenta and to severe hemorrhage, either 
into the gestation sac or into the peritoneal cavity. In the latter stages 

34 



^30 GYNECOLOGY. 

of pregnancy, such hemorrhage almost invariably is fatal. A woman 
with an intraligamentary pregnancy, with a placenta situated above the 
f^tus, runs a greater risk of losing her life than she would from placenta 
praevia. A tubal placenta which is situated above the embryo has its 
structure so damaged by rupture as to render it an inefficient respiratory 
organ, and the constant effects upon the embryo are very marked. The 
fetus from such a gestation rarely attains satisfactory growth. The 
fetus rarely lives more than a few days or weeks. Frequently it is ill- 
formed, suffering from hydrocephalus, club-foot, spina bifida, ectopia 
of the viscera, and other deformities. When normal in shape, it is ex- 
ceedingly defective in size. One case is recorded in which the tubal sac 
contained two embryos measuring eleven centimeters in length. They 
were united by a band in the thoracic region. Dr. M. Price reported 
a well-formed ectopic fetus which survived operation and was healthy 
subsequently. The amount of hemorrhage in an incomplete rupture 
will depend much upon the situation of the placenta. If the placenta 
be attached to the peritoneal surface and rupture takes place over it, 
the bleeding will be excessive and possibly will result in the death of the 
patient unless prevented by surgical interference. If the placenta is 
situated on the opposite side to that on which rupture occurs, the envelopes 
may protrude, but little bleeding will follow, and the sac becomes rein- 
forced by plastic exudate and adhesions. The sac wall is then formed by 
the uterus, the bladder, the parietes or pelvic peritoneum, and the coils 
of intestine. 

A woman thirty-four years of age entered my service at the Jefferson 
Hospital, May i6, 1910. She had the following history: Puberty was 
established at the age of twelve years and the periods lasted from five to 
seven days with a free flow attended with dysmenorrhea the first two days. 
She was married at twenty-two years of age, and two years later, had a 
child after normal labor. She had enjoyed good health until March, 
1909, when, without warning, she was seized with a severe attack of pain 
in the left lower abdomen. In the absence of any other apparent cause, 
her physician attributed this to a "cold." In a few days the distress 
subsided, and she experienced no further inconvenience until the following 
June. During this period her menstruation was regular. On the 
eighth of June she had a regular period which was accompanied by 
severe pain similar to the previous attack in March. Subsequently she 
was never free from abdominal discomfort and the menstrual flow for 
the next six periods was a muddy discharge lasting three or four days. 
During these later months an enlargement of the abdomen was noticed 
and in January of 1910 she felt what she believed to be fetal movements. 
These movements continued until March, after which they ceased. She 
had at this time a bloody discharge accompanied with severe abdominal 
pain. Her family physician made a diagnosis of ovarian cyst. 

On admission to the Hospital the patient had a normal temperature, 
pulse and respiration rate. Her abdominal walls were thin and revealed 
an ovoidal tumor which was movable and not tender to pressure. The 
mass extended a hand's breadth above the umbilicus and filled the abdo- 



ECTOPIC GESTATION. 53I 

men from side to side. While quite firm in consistency, it imparted the 
sensation of elasticity. The abdomen was opened on the nineteenth of 
May, by a long median incision and the intestines were packed back 
after separation of firm omental adhesions. The tumor was adherent 
at the pelvic brim and in the floor of the pelvis. These adhesions were 
separated without difficulty, the pedicle ligated and the mass removed. 
The tumor was the size of a small watermelon and weighed nine pounds. 
The mass was quite elastic, but solid portions could be recognized within 
it. (Fig. 456.) When the tumor was incised, a large quantity of dark 




Fig. 456. — An Ectopic Gestation Sac Simulating an Ovarian Cyst. 

brown fluid was discharged and a full term fetus revealed. (Fig. 457 •) 
The fetus weighed four and a half pounds and measured eighteen 
inches in length. The patient was discharged on the nineteenth of 
June in good health. 

Secondary Rupture. The extraperitoneal rupture causes the formation 
of a secondary broad ligament gestation sac which increases in size and 
may undergo rupture subsequently. The danger is much increased 
when the placenta is situated above the fetus. As the pregnancy pro- 
gresses the peritoneum becomes stretched and is separated from the 



532 GYNECOLOGY. 

adjacent parts and the viscera. The sac extends into the abdomen and 
strips the peritoneum from the anterior wall to a greater extent than an 
overdistended bladder would. When the posterior peritoneum is thus 
raised up, the rectum, as well as the posterior surface of the uterus, may 
be deprived of serous investment. The placenta is insinuated between 
these parts, and secondary rupture may result at any time between the 
twelfth week and the completion of the term. The effects of this secondary 
rupture depend upon the injury to which the placenta is subjected. 




Fig. 457. — Sac Incised Exposing Full Term Fetus From an Ectopic Gestation. 

After the middle period of pregnancy has passed, if the placenta is 
involved (as it is sure to be, owing to its position above the fetus) the con- 
sequence will be frightful hemorrhage and rapid death. Earlier in the 
course of the pregnancy the hemorrhage is not so severe, and may be 
arrested by prompt surgical intervention. Opening of the sac into the 
peritoneal cavity is recognized as secondary intraperitoneal rupture. If 
the fetus occupies the upper portion of the sac and the placenta is attached 
below, the former may escape among the intestines. Secondary rupture 
does not always occur. The patient may go to term, spurious labor 



ECTOPIC GESTATION. 533 

follow, the liquor amnii be absorbed, and the placenta disappear. If 
the extra-uterine pregnancy has not been suspected, and its course not 
disturbed there may result the formation of a mummified fetus, or 
lithopedion, which may be discovered years later. 

Secondary intraperitoneal rupture may occur at any time between 
the twelfth week and term. When it occurs at or near term, the belief 
is perpetuated that the fertilized ovum had tumbled into the peritoneal 
cavity, to ingraft itself upon the serous membrane and develop there. 

The occurrence of primary peritoneal pregnancy is so rare as to render 
its existence exceedingly problematical. The cases of abdominal preg- 
nancy with rare exceptions have their original development in the Fallopian 
tube. When it develops in the uterine end of the tube, particularly 
that portion which traverses the uterine wall, it is termed a tubo-uterine 
pregnancy. This form of pregnancy is not frequent, and readily can be 
confounded with pregnancy in one cornu of a bicornate uterus. The 
tubo-uterine gestation differs in its course, relations, and mode of 
termination from the purely tubal form. Primary rupture generally 
occurs before the eighth week, and the pregnancy is rarely continued 
without rupture beyond the twelfth week. The tubo-uterine gestation 
sac may rupture in two directions: into the peritoneal cavity, causing 
frightful hemorrhage and a rapidly fatal result, or, resistance being slighter 
toward the uterine cavity, the fetus and envelopes may be pushed into 
the uterus and terminate as in an intra-uterine conception. The intra- 
peritoneal rupture is more rapidly fatal than in the tubal form, and 
causes severer hemorrhage, because the uterine wall is more vascular 
and the sac is situated in closer apposition to larger vessels. Tubal 
and tubo-uterine pregnancy have the following distinctive character- 
istics: tubal pregnancy is very common, tubo-uterine rare; the tubal 
gestation sac is very thin, the tubo-uterine very thick. 

The termination can be: i. Intraperitoneal rupture for each, or 
2. Rupture into the intraligamentary space. In the tubo-uterine pregnancy, 
rupture can occur into the uterine cavity, with the discharge of the fetus 
through the vagina. 3. In the tubal, abortion can result, and, as in the 
primary rupture, date from the third to the twelfth week. In the tubo- 
uterine, rupture occurs at any time from the fifth to the twentieth week. 
Ovarian pregnancy, pure and simple, is extremely rare, and while there 
are cases in which careful examination has disclosed ovarian structure 
in the sac wall, with the tube free and unaffected, yet we are not prepared 
to admit that the condition may not have originated from the tube, for 
it is very doubtful whether the ovum will develop when not attached to 
the Miillerian structure. The majority of cases of ovarian pregnancy 
are undoubtedly tubo-ovarian, in which the embryo was originally situated 
in the orifice of the tube and has been partly extruded without loss of its 
vitality. As might be inferred, the life of the embryo in a tubal pregnancy 
is necessarily precarious. After rupture, undoubtedly the pregnancy 
may continue until full term. Symptoms of labor set in, during which 
the gestation sac may burst into the peritoneal cavity. If this catastrophe 
is avoided, the fetus dies. The body remains quiescent or produces various 



534 



GYNECOLOGY. 



forms of disturbance. Thus, the liquor amnii is absorbed; the tissues of 
the fetus become mummified or partly calcified, and form a lithopedion. 
The softer parts are converted into adipocere or undergo other forms of 
decomposition. The placental tissue is gradually absorbed and dis- 
appears. 

Mummification is attended with absorption of the fluids, while the 
soft parts are converted into a dried tissue similar to that which follows 
when a dead cat permitted to remain under an old building, becomes a 
dried cat. An extra-uterine fetus can be retained in the body for a long 
period of time. Cheston reports a lithopedion carried for fifty-two 
years; Barnes, one forty- two. That a fetus may be carried this length 
of time does not necessarily indicate that it will not prove a source of 
danger to the patient. That these gestation sacs may be carried for a 
long time is illustrated by the following history of a patient in my service 
at St. Joseph's Hospital. A German woman, thirty-four years of age, 




>FiG. 458. — Calcified Ectopic Gestation Sac Carried Over Ten Years (a, Femur; h, Tooth; 
, . c, Tube and Ovary; d, Orbital Plate of Frontal Bone). 



came to this city ten years before her admission to the Hospital. She 
has given birth to three children after normal labors and never had an 
abortion. For ten years she had an abdominal tumor, the history of which 
was indefinite. It afforded no signs to indicate an ectopic gestation. 
Six months prior to her admission she was taken with severe pain in the 
right pelvic region and had frequent attacks of fainting. The tumor 
became tender to pressure and locomotion was impossible. These acute 
symptoms subsided after a few days, but the patient was incapacitated 
from this period until her admission. She then had to the right of the 
umbilicus a tumor which was slightly movable, irregularly nodular and 
dense in consistency. It was supposed to be a parasitic fibroid. When 
the abdomen was opened, a large fetal-head-sized mass was revealed. 
As the tumor was separated its connection with the right Fallopian tube 
was rendered evident. It was enveloped in the omentum and adhered 
firmly to the mesentery. After its removal, the stump was sutured, the 



ECTOPIC GESTATION. 



5^5 



hypertrophied omentum removed in sections, and the torn mesentery 
was sutured. The patient had an uninterrupted convalescence and was 
discharged in twenty-five days. The specimen removed weighed 
three pounds and contained much calcareous material in the sac wall. 
On its surface could be seen the femur, a tooth, and the outline of the 
orbital plate. Pathogenic micro-organisms can find entrance to the sac 
through the adjacent hollow viscera, and at any time produce serious 




Fig. 459. — Photograph of the Skeleton Dissected and Arranged from the Original Specimen 

Seen in Former Figure. 

trouble. Suppuration follows, pus finds its way through the sac-wall, 
and penetrates the vagina, uterus, bladder, or rectum. Through any 
of these openings fragments of fetal tissue escape from time to time, 
causing frightful distress and necessitating operation for relief. The 
existence of a lithopedion or macerated fetal skeleton does not preclude 
subsequent pregnancy. One case came under my observation in which 
a woman with a good-sized and distinctly well-defined lithopedion 
'gav€ birth to two children. 



53 6 GYNECOLOGY. 

Symptoms which should lead one to suspect the existence of an ectopic 
gestation are dependent upon the duration and course of the pregnancy. 
A history will be obtained of disordered menstruation, the patient having 
missed one or more periods. The ordinary symptoms of pregnancy 
are present and she has supposed herself pregnant. She may have 
experienced a sensation of uneasiness or distress over the region of the 
ovary and tube upon one side, associated with frequent and sudden attacks 
of colicky pains. These pains may have been of severe, cutting character, 
paroxysmal, and occasionally intense. In other cases without any 
premonition pain of a tearing, cutting character will occur, so severe and 
lancinating as to cause the patient to fall and become unconscious. This 
phenomenon may be followed by repeated attacks of syncope in which 
the countenance of the patient becomes pale, anxious and covered with 
clammy perspiration. The lips are pale and blanched, respiration is 
sighing, the sight obscured, there is a sensation of darkness or even 
blindness, frequently her mind wanders, she may remain unconscious, 
or pass from one attack of syncope to another. The pulse at the wrist 
becomes exceedingly feeble, faint, and imperceptible. The temperature 
is subnormal, and all the indications of approaching dissolution are 
present. Generally the symptoms are not so marked. The patient is 
weak, debilitated, shows symptoms of shock or collapse, soon rallies, 
with recurring attacks of a similar character, which indicate that the 
hemorrhage has again recurred or is slowly continuing. In other cases 
the progress is insidious. A small aperture exists; the walls have been 
stretched. Plastic exudation is thrown out and the pregnancy may 
progress without further accident. The tube may rupture either intra- 
peritoneally or extraperitoneally. The symptoms of the two varieties 
will be found entirely different. The gravity of the former is much 
greater, but will depend upon whether the rupture has been complete 
or incomplete, and also upon the situation of the placenta. When the 
rupture occurs from the site of the placenta, even though incomplete, 
hemorrhage can be so severe as to cause the death of the patient if inter- 
vention is not instituted. According to the intensity of the hemorrhage, 
the patient may either die in the first attack, that is, within half an hour 
or an hour after the first symptoms or rally slightly with an apparent 
recurrence of the hemorrhage, followed by death within less than twenty- 
four hours. Should the patient survive twenty-four hours and rally, 
her strength may gradually return and recovery follow, though a secon- 
dary hemorrhage may develop and result in a fatal termination. When 
the patient survives the hemorrhage and shock, the accident is followed 
by more or less tenderness over the abdomen and by abdominal disten- 
tion, symptoms indicating the occurrence of localized peritonitis. In the 
early stage of hemorrhage no physical signs of its existence can be recog- 
nized. Possibly a large quantity of blood in the abdominal cavity of a 
thin woman could be recognized by the sensation of fluctuation. In 
twenty-four hours the blood will accumulate in the pelvis, and we then 
observe a sensation of fluctuation and slight resistance by vaginal palpa- 
tion. Change in the position of such a patient permits the collection to 



ECTOPIC GESTATION. 537 

flow out of the pelvis, when its presence will no longer be recognized. 
If the pelvis is lowered again, the accumulation returns. The coagulated 
blood causes more or less irritation, which results in the exudation of 
plastic material and the occurrence of a localized peritonitis. The ab- 
domen becomes tender to the touch, febrile reaction occurs, and the 
temperature, instead of being subnormal, now rises to ioi° F. or even 
103° F. The patient may experience distress from pressure of the mass 
on the rectum or against the uterus and bladder, which produces frequent 
micturition — even incontinence. With the advent of plastic peritonitis 
the collection becomes encysted. The patient will often suffer from 
nausea and abdominal distention. The watery portions in such a col- 
lection become gradually absorbed and the mass is more apparent and 
resistant. The uterus may be pushed upward and forward. The in- 
testines are raised up and form a part of the wall of the sac. The col- 
lected mass varies in its consistence: sometimes it is hard, sometimes 
soft, or the same mass may have several points of softening. The uterus 
may be enveloped by the collection, producing what is known as an envel- 
oping uterine hematocele; the functions of the rectum and bladder 
may be impaired greatly by the compression of the mass against these 
organs, often causing symptoms of intestinal strangulation and retention 
of urine. Pressure upon the nerves of the pelvis frequently produces 
severe neuralgia of the lower extremities. Even when suppuration does 
not occur, irregular attacks of fever frequently are the result of peritoneal 
reaction. The course and progress of the disease are essentially 
chronic, though repeated attacks may occur. The congestion which 
takes place at the menstrual periods may result in acute symptoms. 
Suppurative change in such a collection is ushered in by an aggravation 
of both the local and general symptoms, chills, elevation of temperature, 
profuse sweating, leukocytosis; the tumor increases in size and under- 
goes softening; the mass may subsequently perforate into the rectum, 
causing the evacuation of dark, purulent, exceedingly offensive material 
in the stools, which may cause more or less irritation of the rectum. 
These discharges are followed by cessation or disappearance of the 
tumor. Perforation into the vagina or bladder may occur, though these 
are rare. Perforation into the abdominal cavity is fortunately infrequent. 
When it does result, a violent attack of general peritonitis follows. The 
occurrence of rupture of the tubal sac is frequently associated with dis- 
charge of blood from the vagina and severe uterine pain. The uterine 
pain or the pain from the rupture may cause the victim to believe that 
an abortion is impending. This suspicion may be confirmed still further 
by the discharge of a cast from the uterus or of shreds of tissue, asso- 
ciated with clots, leading both the patient and her medical attendant to 
believe that an abortion has occurred. When the hemorrhage is slight 
and the ovum retains its connection with the tube, the fetus may continue 
to full development, and even reach full term. A pregnancy situated 
posterior to the uterus may reach full term without causing the patient 
to suspect that an abnormal condition exists. It is only after the beginning 
of labor, when an examination is made, that the true state of affairs is 



538 GYNECOLOGY. 

recognized. Even then it is not always recognized and the spurious 
labor may terminate without the discharge of the fetus and the sac 
undergo subsequent changes. 

Diagnosis comprises: i. The recognition of extra-uterine pregnancy 
preceding rupture; 2. The determination of rupture or abortion with 
intraperitoneal or extraperitoneal hemorrhage and death of the fetus; 
3. Secondary rupture; 4. Continued growth of the embryo after rup- 
ture; 5. Peritonitis; 6. Suppuration. 

1. Preceding Rupture. Frequently the victim of misplaced conception 
does not apply to her physician until the occurrence of a violent, tearing 
pain, indicating rupture. The distressing symptoms prior to this occur- 
rence are rarely sufficiently definite to demand a physical examination. 
Such an examination is generally requested in order to ascertain the 
existence of the supposed normal pregnancy. However, the frequent oc- 
currence of ectopic gestation should lead to the careful investigation of 
every patient who gives symptoms of being pregnant, where there is a 
previous history of more or less extended sterility, of attacks of pelvic 
inflammation, especially if the latter has originated from gonorrheal in- 
fection. Such an examination is particularly indicated when the patient, 
having missed a period, complains of a sensation of uneasiness or distress 
in one side of the abdomen, associated with frequent and sudden attacks of 
colicky pain. Every such patient should be subjected to a careful 
examination. Slight enlargement of the uterus, with some tenderness 
in the pelvis, more marked upon one side, associated with a more or less 
spherical or rounded distention of the tube, should increase the suspi- 
cion of ectopic gestation. This suspicion would be confirmed by finding 
increased vascularity in the broad ligament, causing marked pulsation of 
its vessels. This pulsation is distinctly recognizable upon the affected 
side, while the pulsation on the opposite side is not defined. The exam- 
ination should be made with the utmost gentleness, for rough manipula- 
tion or marked pressure in the practice of the bimanual procedure can 
very readily rupture a sac which is so thin as to require only slight amount 
of additional pressure. Where the sac is of considerable size, it is unwise 
to subject it to much force in the examination, unless the operator is 
prepared for immediate operation should rupture occur. It has been my 
unfortunate experience with a patient in whom the pulsation was as dis- 
tinct as if the finger were placed over the radial artery, to have the sac 
ruptured by her physician, during examination. The patient succumbed 
to the subsequent operation. Dr. J. M. Fisher, my assistant, reports 
two cases in which he has observed the rupture of an ectopic gestation 
during examination. 

2. Rupture of an ectopic gestation sac may be suspected when the pa- 
tient gives a history of having failed to menstruate for one or two periods 
and has exhibited the ordinary symptoms of pregnancy. She has prob- 
ably had more or less discomfort upon one side, with frequent colicky 
attacks, when suddenly, without warning, there has been an attack of 
most violent, tearing pain, followed by syncope, all the symptoms of 
internal hemorrhage, with oncoming collapse. I have seen such a patient 



ECTOPIC GESTATION. ^jp 

in the space of ten minutes pass from a condition of apparent good health 
to one which seemed to threaten approaching dissolution. The face 
was blanched, pale, exceedingly anxious looking, covered with cold, 
clammy perspiration; the pupils dilated, eyes expressionless, rolling from 
side to side; sighing respiraton; pulse rapid, feeble, sometimes almost 
imperceptible. The patient complained of being unable to see, every- 
thing appearing dark about her. Sometimes marked nausea and vomit- 
ing are present. The slightest movement, even raising the head of the 
patient, is followed by more or less profound syncope. Such a train 
of symptoms should awaken in the mind of the observer the absolute 
conviction that an internal hemorrhage is occurring, and the association 
-of such a group of symptoms would indicate its origin from an ectopic 
gestation. A physical examination affords very little information, for 
at this time the tumor is insufficiently large and without the necessary 
firmness to afford the sensation of resistance. The physical signs 
are consequently indefinite. When bleeding is extensive, and the ab- 
dominal walls thinned and not very resistant, a sensation of distention 
may be noted and even fluctuation recognized. \ATien the hemorrhage 
is not so profound as to endanger life, the watery portions of the effused 
blood are gradually absorbed and leave a more or less resistant clot, 
which can be felt as a firm mass in the pelvis. In the absence of previous 
history of recent inflammatory trouble or the previous existence of a 
growth, it must be recognized as effused or clotted blood. The accumu- 
lation is generally retro-uterine. A large extravasation may fill the pelvis, 
push the uterus forward, and raise the intestines above it. (Fig. 446.) In 
other cases the uterus may be found in a state of retroversion, while a 
mass is situated in front and forms an ante-uterine hematocele; or in 
very large accumulations the uterus may protrude through it, producing 
what is known as a circumuterine hematocele. Hemorrhage dangerous 
to life, and productive of the most profound anemia, may arise without 
rupture, as in tubal abortion, or when the villi have penetrated the wall 
of the tubal sac and bleeding occurs from their surfaces. These per- 
forations may be so minute as to be unrecognizable by the naked eye, 
except for a thrombus projecting from the external tubal surface. The 
tubal abortion in its earliest stage causes no marked physical manifesta- 
tions outside of those symptoms which indicate an internal hemorrhage. 
Later, however, percussion will be dull over the flank and lower abdo- 
men' and the blood-clots in the tube, filling up the sac, produce a large, 
sausage-shaped mass, which may be firm and resistant. The patients 
in whom rupture has occurred may present successive attacks of shock 
and syncope. Thus, a patient bleeds until the blood pressure is greatly 
reduced. A clot forms, plugs the vessel temporarily, and the circulation 
is restored. If, however, injudicious efi'orts are made to revive the patient 
by hypodermatic injections of strychnin, digitalin, or intravenous injec- 
tion of salt solution, the clot is washed or driven out and hemorrhage 
again recurs, with a repetition of the former symptoms. Noble has re- 
ported cases in which the rupture and hemorrhage have been associated 
with a rather rapid and marked rise of temperature. The general rule, 



540 



GYNECOLOGY. 



however, is that where hemorrhage is marked the patient shows a sub- 
normal temperature, as would be expected in cases of shock and threat- 
ened collapse. The temperature rarely is elevated until some days after 
the hemorrhage and then is not high. Undoubtedly, the elevation of 
temperature is due to degenerative changes in the collection, possibly 
from the fibrin-ferment, or more likely from partial infection by organisms 
from the intestinal canal. At the time of this elevation of temperature 
the peritoneal exudate is thrown out. This forms barriers and confines 
the blood accumulation within the pelvis. The watery portions of the 
blood become absorbed, until a more or less distinct and well-defined 
mass of clotted blood is perceived. In extraperitoneal hemorrhage the 
symptoms are much less acute. Shock or collapse is less marked, 
although we still have symptoms which, to a limited degree, should lead 




Fig. 460. — Ectopic Gestation Sac Ruptured, Showing Fetus. 

one to suspect internal hemorrhage. Examination will disclose on one 
side of the pelv s a mass which may fill up and distend the broad ligament. 
The tumor may be quite tense and push the uterus to the opposite side. 
The condition differs from tubal disease in that the broad ligament is 
distended by it. There has been an absence of recent inflammatory 
trouble, and the patient does not present the characteristic symptoms 
of inflammation. In the intraperitoneal variety the irritation of the ac- 
cumulated blood causes certain reactive symptoms and sometimes the 
development of peritonitis. The temperature becomes elevated, pulse 
rapid, the abdomen tender and sensitive to pressure, but the symptoms 
are not so acute as in marked inflammation. The rupture and internal 
hemorrhage are usually associated with a discharge from the uterus of 
decidual membrane, either as a complete cast of the cavity or in the form 
of shreds mixed with clots. The cast may show the orifice of the Fal- 
lopian tubes and internal os. Inquiry should be made with regard 
to this symptom, and, when possible, the discharged material should be 
carefully examined. It is important to differentiate it from the decidua 



ECTOPIC GESTATION. 541 

thrown off in some forms of dysmenorrhea. That of pregnancy is from 
six to eight millimeters in thickness, while that of menstruation rarely 
exceeds two or three centimeters in length and is scarcely two millimeters 
in thickness, is translucent, rarely passed entire, and consists of the 
compact layer of the epithelium. When the symptoms have been slight 
and the woman has considered herself the subject of an abortion, she may 
not present herself for examination until the enlarged fetal sac causes a 
suspicion of the continuation of the pregnancy — even then, she may not 
consult a physician. 

3. Secondary ruplure necessarily follows a primary rupture, which, in 
the majority of cases, has taken place in the broad ligament. The rupture 
has occurred in such a way as not to interfere with the vitality of the ovum. 
Retaining its vitality, it enlarges its implantation, and in its growth spreads 
out the broad ligament until the latter is no longer able to retain it, when 
from pressure the thinned wall finally ruptures and severe hemorrhage 
takes place into the peritoneal cavity. The history of repeated attacks 
of pain and distress, of symptoms of internal hemorrhage, of the enlarging 
abdomen, and, finally, the cutting, agonizing pain associated with rupture 
into the peritoneal cavity should be sufficient data upon which to base the 
diagnosis of secondary rupture. Both in primary and secondary rupture 
the amount of hemorrhage will depend upon its relation to the site of the 
placenta. Where the rupture takes place over the latter, the hemorrhage 
may be very profound and so rapid as to result in death of the woman 
before measures can be instituted for her relief. 

4. Continued Growth of the Embryo after Rupture. Growth may take 
place in the broad ligament, spreading it out, or, in those cases in which the 
embryo has become reimplanted upon the surface of the peritoneum, the 
ovary, or in a continuation of the tube, the growth advances as it would in 
ordinary pregnancy. The fetal movements are recognized, the enlarge- 
ment continues, and the patient imagines herself normally pregnant. 
On physical examination of such a patient the parts are more distinctly 
defined by bimanual palpation than if the mass were situated within the 
uterus, as there is less structure intervening between the fetus and the 
palpating hand. Recognition of the fetal heart sounds is absolute indi- 
cation of the existence of pregnancy. After the completion of the normal 
term of pregnancy in such a patient the appearance of spurious labor, the 
cessation of fetal movements, and the changes which come under observa- 
tion months later, may greatly increase the obscurity of the condition. 

A patient came under my observation who supposed herself pregnant. 
She suffered from a bloody discharge, with considerable pain, at the end of 
the second month, which led her to think that an abortion had occurred. 
The supposed abortion occurred in February. Her g^bdomen consequently 
became enlarged, and in the following October she went into labor. Pains 
continued for two days, and after the movements ceased her menstrual 
periods returned. In April she presented a tumor as large as in a preg- 
nancy at full term, over which there was distinct fluctuation and marked 
resonance. A thin-walled sac was recognized, but no resistant mass. 
Vaginal examination disclosed behind the uterus a tumor which filled 



542 GYNECOLOGY. 

Douglas' pouch. The uterus was enlarged and was situated directly int 
front of the tumor. Percussion gave resonance everywhere. No dulness 
could be distinguished although fluctuation was distinct. The diagnosis 
was an ectopic gestation, with death of the fetus, decomposition in th& 
fetal sac, and the formation of gas. This diagnosis was confirmed by 
opening the abdomen and finding posterior to the uterus a sac which 
contained a macerated fetus and a considerable quantity of offensive 
fluid. 

5. Peritonitis may take place as a result of rupture of the sac, the escape 
of its contents into the peritoneal cavity, the accumulation of blood from 
a large hemorrhage, and its irritation upon the pelvic peritoneum. Unless 
relief is afforded, extensive matting together of the intestines and pelvic 
structures occurs, requiring early operative interference for relief. Peri- 
tonitis may be produced, also, by the death of the fetus and infection of the 
sac. Its occurrence is indicated by pain and tenderness over the abdomen, 
distention of the belly, assumption of the dorsal position, and distress dur- 
ing the evacuation of the bladder or movement of the bowels. 

6. Suppuration. Suppuration in an ectopic gestation may follow its 
rupture, so that the contents of such a sac become sanguinopurulent. 
Suppuration also takes place in later stages of a pregnancy which has gone 
on to full term; the fetus has subsequently become macerated, mummified, 
or even a lithopedion has formed. Suppuration may occur months or 
even years after a pregnancy, and lead to the evacuation of the sac or to its 
rupture into the intestine, the bladder, the vagina, or through the ab- 
dominal wall. Fragments of the fetus and its bony structure will be 
discharged. Suppuration will be indicated by increased pain and distress, 
by recurring chills, sweating, elevation of temperature, and the ordinary 
symptoms associated with suppurative processes. That the suppuration 
originated in an ectopic gestation will be demonstrated by the previous 
history of the case. This is made absolutely certain when the bony 
fragments of the fetus are discharged. 

Differential Diagnosis. Tubal and uterine pregnancy may coexist. 
Uterine may follow tubal pregnancy, or repeated uterine pregnancies may 
occur subsequent to the formation of a lithopedion. Tubal pregnancy 
may be bilateral. Its frequent occurrence in the remaining tube after 
removal of a tubal gestation sac has led some operators to advocate -the 
removal of both appendages in every case of tubal gestation. Tubal 
pregnancy may coexist with ovarian and tubo-ovarian tumors. In a case 
I saw with Dr. J. M. Fisher the symptoms justified his diagnosis of rupture 
of a tubal gestation sac. From its outline a mass upon the left side of the 
pelvis was considered to be a large extraperitoneal hematocele, which I 
decided to evacuate by a vaginal incision. A large quantity of clotted 
blood was evacuated, above which was a smooth cyst, too large to remove 
through the vagina. The ruptured tubal gestation sac was upon the 
opposite side. The removal of the cyst was effected by an abdominal 
incision. 

The following conditions may be confounded with ectopic gestation: 
I, uterine pregnancy; 2, pregnancy in a bicornate uterus; 3, a retroflexed 



ECTOPIC GESTATION. 543 

gravid uterus; 4, spurious pregnancy; 5, ovarian tumors; 6, uterine tumors; 
7, intraligamentary tumors; 8, accumulation of feces in the rectum. 

I. Uncomplicated u erine pregnancy is generally more easily recog- 
nized by the change in shape and size of the organ. In ectopic gestation 
the jug-like shape or outline of the fundus is wanting. A sac or mass^ 
rather sharply defined, will be found in one of the tubes, if rupture has not 
occurred, and the subjacent vessels will pulsate more distinctly than upon 
the opposite side. After rupture the condition is distinguished by more or 
less severe shock, profound anemia, and the appearance of a large mass in 
the pelvis without a history of previous inflammatory phenomena. The 
introduction of the sound and the use of the curet to secure decidual tissue 



Fig. 461. — Large Ectopic Gestation Sac. 

have been advocated, but these procedures are not free from danger. In 
possible uterine pregnancy and abortion the danger of infection must not 
be overlooked. The investigation for decidua may be misleading, as it 
previously may have been exfoliated. The tissue removed by a curet can- 
not be certainly distinguished from that which will be caused by inflamma- 
tion. The procedure endangers the development of septic processes, and 
will complicate a tubal gestation if any exists. 

2. Pregnancy in one horn of a bicornate uterus may be impossible to 
differentiate from a tubo-uterine or an interstitial pregnancy. Fortunately, 
the treatment of the two conditions is similar, and is almost equally urgent. 
A tubal gestation is situated at a greater distance from the uterus. 

3. The retroflexed pregnant uterus is recognized by palpation. We 
are able to trace the tumor back from the cervix, and the smoothly outlined 
fundus is capable of considerable movement. 



544 GYNECOLOGY. 

4. Careful analysis of the symptoms, associated with the accurate 
consideration of physical signs, will guide to a correct diagnosis. After the 
abdomen has been opened, it is a grave error to mistake an extraperitoneal 
pregnancy for sarcoma or myoma. 

5. Ovarian tumors are usually differentiated by their history. It is 
only when one of these growths has produced no symptoms by which its 
presence could be suspected, and is suddenly complicated by an acute 
attack, during which or subsequent to which examination discloses its 
presence more or less fixed in the pelvis, that error is possible. Such a 
train of symptoms is readily produced by twisting of the pedicle of a small 
ovarian or a broad-ligament cyst. I saw a young unmarried woman who 
presented a history of having had a severe attack of pain upon the right 
side, which was pronounced appendicitis. A movable mass could be felt 
above the brim of the pelvis upon the right side, but there was no inflam- 
matory exudation. Notwithstanding her good character, ectopic gesta- 
tion was regarded as a possibility. Abdominal incision disclosed a broad- 
ligament cyst beyond the ovary, closely attached to the outer part of the 
tube, whose pedicle had twisted, causing hemorrhage into the cyst and 
twisted portion of the tube, with the effusion of a large quantity of free 
bloody serum in the peritoneal cavity. 

6. When, in an extra-uterine pregnancy, the fetus is dead, the fluid 
portions have been absorbed, and the mass is hard and firm, with its sac 
closely adherent to the side of the uterus, the physical signs are frequently 
insufficient to establish the differential diagnosis between it and an intra- 
ligamentous myoma. 

7. Intraligamentary tumors are easily confounded with ectopic gesta- 
tion. Frequently the diagnosis can be determined only after abdominal 
incision. A patient was brought to me with the following history: 
married nine years she had never been pregnant; six weeks before ad- 
mission she was seized with severe pain in the left side, and subsequent 
inflammatory symptoms, which confined her to bed the greater portion 
of the time. A mass, quite resistant, and firmly fixed by adhesions was 
felt to the left and in front of the uterus. The long period of sterility, 
sudden onset, and more or less fixed tumor, not previously recognized, led 
me to suspect tubal gestation with intraligamentary rupture. The incision, 
however, disclosed an intraligamentary ovarian cyst. The thick walls, 
which had undergone a degenerative process, probably explained the 
sudden onset. 

Not infrequently the diagnosis can be determined only by incision. 
An ectopic gestation is found when operations are performed for other 
conditions, and the reverse. 

8. Careful examination should exclude fecal accumulation. Ordinar- 
ily, the latter condition is determined by the possibility of indenting the 
fecal masses. When there is any doubt, an expression of opinion should 
be withheld until a complete evacuation of the bowels can be secured by 
an active purgative, supplemented by free rectal enemas. 

The differential diagnosis of tubal rupture is often difficult. Rupture 
is simulated by lesions of the abdominal viscera, such as perforating ulcers 



ECTOPIC GESTATION. 545 

in the stomach, duodenum, small intestine, and vermiform appendix; 
rupture of a pyosalpinx; torsion of the pedicle of a small ovarian cyst; acute 
intestinal obstruction; renal and biliary colic. A case of tubal gestation 
has been brought to operation as a supposed strangulated hernia. The 
diagnosis of tubal rupture can always be rendered certain by a puncture 
through the posterior vaginal fornix, when the rupture will be indicated 
by the discharge of dark-colored blood. The vaginal puncture, affords in 
addition, opportunity for the digital exploration of the pelvic viscera. 
Such an investigation permits palpation of the tubes and ovaries and the 
recognition of existing abnormalities. 

The following table, modified by Greig Smith from Webster, presents 
in a convenient form a summary of the pathologic and clinical features 
of ectopic gestation: 

ECTOPIC GESTATION. 

Ampullar Gestation beginning in the ampulla of the tube. 
Persisting (rarely goes to full term). 
Rupture (the usual result): 
Into broad ligament: 

Gestation continues there. 

Secondary rupture into peritoneal cavity. 

Gestation terminates: 

By formation of hematoma. 
By suppuration. 
By mummification. 
Into peritoneal cavity: 

Gestation continues, the placenta remaining in the tube, the fetus and 
the membranes being in the cavity; or 

Secondary implantation may occur on the peritoneal surfaces. 
Gestation terminates: 

By death of patient from hemorrhage or shock. 
By absorption of the mass. 

By mummification or by adipocere or lithopedion formation. 
By delivery of fetus through surgical procedure. 
Destructimi of gestation: 
By tubal abortion. 
By formation of mole. 
By hematosalpinx. 
By suppuration. 

By absorption after early death. 
Interstitial Gestation developing in the intestinal portion of the tube. 
Persisting (the gestation may go to term). 
Rupture : 

Into the peritoneal cavity. 
Into the uterine cavity. 

Into both the peritoneal and uterine cavities. 
Between layers of broad ligament. 
Destruction of gestation and retrogressive changes in fetus and envelopes. 
Ineundibular Gestation in the outer end of the tube. The ovary may form 
part of the wall of the sac. 

Prognosis. Extra-uterine pregnancy at any stage of its progress 
must be regarded as a condition fraught with the greatest peril to the 
patient. It should be regarded as just as positive an indication for treat- 

35 



546 GYNECOLOGY. 

ment as would be the presence of malignant disease. If discovered before 
the rupture of the sac, the patient is in danger from hemorrhage. The 
longer the condition progresses, the graver is the peril. After rupture, 
with death of the fetus, the patient is not free from danger, as the collection 
of blood — the hematocele — may become infected from its proximity to the 
hollow viscera, and cause the, formation of an abscess or the development 
of pyemic symptoms. If the fetus survives the rupture, its subsequent 
development only increases the danger. A secondary rupture, with 
escape of the sac contents into the peritoneal cavity, or the frightful 
hemorrhages which result in some conditions, may prove immediately 
fatal. The woman may go on to full term and the fetus die, then undergo 
retrogressive processes, which may at any time, even after years of quies- 
cence, become infected, and result in the formation of abscesses, per- 
foration of viscera, and escape of the contents of the sac. As the nutrition 
of the fetus in the majority of cases is defective, from unfavorable im- 
plantation of the placenta, frequently from pressure upon it, the fetus is 
generally imperfectly developed, often undersized, suffering from hydro- 
cephalus, spina bifida, club-foot, and other deformities. The preservation 
of the life of such an individual should not be considered when it is recog- 
nized that the life of the mother is constantly in peril. Furthermore, the 
fact should be taken ipto account that, even under the most favorable 
circumstances, the chances for the fetus are very greatly decreased, and 
that, even when delivered alive, its duration of life is short. The statistics 
of Dunning, however, indicate that an operation for the delivery of the 
child during life, when viable, is more favorable for the life of the mother 
than is the delay of the operation until after the death of the fetus. 

Treatment. In a condition replete with such dangers as that of 
ectopic gestation it does not seem the province of the physician to practise 
any other method than one which will afford the greatest certainty of 
relief and can be accomplished with the least danger. This, in my 
judgment, is through surgical manipulation; but, as other methods of 
treatment have been advocated, before entering upon the consideration of 
extirpation, I will consider the substitutes. The substitute methods 
recognized are evacuation of the liquor amnii, injection of poisonous 
substances, elytrotomy, and the application of the electric current. 

The evacuation of the liquor amnii was advocated by Simpson in 1864. 
He treated a case by puncturing the cyst through the vagina without 
killing the child, but the mother died in three days. Braxton Hicks tried 
a similar method in 1865, which killed the child, and the mother died of 
hemorrhage. Greenhalgh, in 1867, had a successful case. James, of 
Philadelphia, in 1867, had a successful case after much tribulation. 
Owing to the great mortality, this plan of treatment has been generally 
abandoned. 

The injection of poisonous materials into the fetus and its enveloping 
fluids was advocated by Joulin in 1863. Morphin is the drug most fre- 
quently used. Other remedies, such as strychnin and ergotin, have been 
employed similarly. Inunctions of mercury, the administration of po- 
tassium iodid, and repeated bleeding have been advocated, but it is difficult 



ECTOPIC GESTATION. 547 

to explain why. The injection of morphin with a hypodermatic syringe is 
practised before the fifth month. Two injections are usually given, 
containing 1/2 of a grain each, at an interval of from eight to fifteen days. 
The treatment may result in severe hemorrhage, septicemia, and perfora- 
tion of an intestinal loop, so that, while apparently a simple procedure, it 
is attended with greater danger than an abdominal operation. 

Elytrotomy, or the removal of the fetus and its contents through a 
vaginal incision, was instituted as early as 181 7 by Dr. King, of Georgia. 
This operation, which has been lately revived, is not by any means a new 
one. In the discussion of hematocele vaginal incision has been advocated 
as a justifiable method of procedure when the condition has become 
chronic; in other words, some time after the hemorrhage has taken place, 
when the vessels are occluded and the fetus is more than likely to be dead. 
In such cases vaginal incision affords an opportunity for clearing away 
the debris without subjecting the patient to so serious an operation as would 
be that through the abdominal wall. But before rupture, or immediately 
following rupture, in order to arrest the hemorrhage, the abdominal in- 
cision should be preferred. When the patient has reached full term and the 
death of the fetus has occured, but as yet without the appearance of sup- 
puration, the vaginal procedure may be chosen : i . When the fetus presents 
the head, breech, or feet, so that it can be extracted without altering its 
position; 2. when it is certain, from the thinness of the structures separat- 
ing the presenting part from the vaginal canal, that the placenta is not 
situated over this part of the sac, and we are not absolutely certain that the 
placenta may not be inserted on the anterior abdominal wall. If it is 
necessary to turn the child in order to deliver it, the vaginal procedure 
should not be considered. Robertson advocates dividing the perineum, 
septum of the vagina, and rectum, but this is an unnecessarily severe 
proceeding. 

The application of electricity for the destruction of the fetus has been 
practised since 1853, There is a difference of opinion, however, among 
electrotherapeutists as to the greater value of the faradic and galvanic 
currents, each having its advocates. This procedure is preferable to all 
those named, but is advisable only in the earlier months of pregnancy. 
In the early stages we must take into consideration the fact that the diag- 
nosis is not always certain. Without doubt, many of the cases reported 
to have been cured by electricity were cases which had undergone rupture, 
and in which the tubal mole or embryo had escaped and lost its vitality, 
and the electric treatment has possibly served to expedite the absorption of 
the exudation — an absorption which would have taken place had electricity 
not been applied. Many cases in which electricity has been applied were 
undoubtedly cases of mistaken diagnosis. It is true that advanced methods 
of examination will differentiate the condition more certainly, but the 
violence required to accomplish this will greatly endanger the rupture of 
the fetal sac. The application of electricity has occasionally been found 
to intensify the contraction of the muscle-fiber of the tube and to result in 
rupture and severe hemorrhage. When the death of the fetus occurs the 
danger does not cease. We frequently find the placenta continuing to 



54^ GYNECOLOGY. 

grow, or rupture may follow, associated with severe hemorrhage and later 
with septicemia. In the application of the current one pole of the battery 
(generally the negative), is applied through either the rectum or the vagina 
in the neighborhood of the ovum. The other pole or a large electrode is 
applied to the abdominal wall directly over the sac and an inch or more 
above Poupart's ligament. The current is used for five to ten minutes, 
increasing it as the sensitiveness of the patient will permit. When 
necessary, the application should be repeated. The practice of this pro- 
cedure is of doubtful utility, and, as has already been mentioned, it is not 
without danger. It temporizes with a condition which menaces life and 
may excite severe tubal contractions which often result in rupture with 
subsequent hemorrhage. 

The risks and difficulties of operative treatment will largely depend 
upon the stage of gestation and the condition of the placenta and gestation 
sac. The surgeon, to be properly prepared to meet all emergencies, 
should consider: 

1 . The measures to be employed before primary rupture or abortion. 

2. The measures required at the time of primary rupture. 

3 . The treatment required after rupture : 
a With intraperitoneal hemorrhage. 

b With extraperitoneal hemorrhage. 

4. The treatment advisable in advanced growth of the embryo: 
a The child alive. 

b The fetus dead, mummified, or reduced to a lithopedion, 

c Following decomposition of the fetus and suppuration of the sac. 

1. The Measures to he Employed before Primary Rupture or Abortion. 
Cases in which opportunity is afforded to operate prior to the rupture 

of the sac are more frequent than formerly, owing to our improved 
methods of diagnosis and to the greater significance given to disorders 
accompanying pregnancy. Too frequently still, the disorder will be 
overlooked until the danger-signal of rupture appears. When the 
symptoms present make it evident that an ectopic gestation exists or is 
extremely probable, the patient should be subjected to operation at the 
earliest possible moment. The danger arising from rupture is so great 
that the patient should be considered in peril of her life until the con- 
dition is corrected. The abdominal incision is the preferable procedure, 
inasmuch as it affords a better opportunity to explore the field, to 
manage adhesionS; and to secure bleeding vessels. The removal of the 
entire sac rarely affords any special difficulty. In a tubo -ovarian preg- 
nancy it is possible that a knuckle of intestine may have become ad- 
herent to the sac. In such cases the removal of the latter must be 
carefully managed, because the changes which take place in the ad- 
herent intestine render it easily torn. In my own experience, failure to 
recognize this possibility led to the necessity of resecting a knuckle of 
intestine for an extensive tear. The patient, fortunately recovered, 
however. 

2. Measures Required at the Time of Primary Rupture. Unfortunately, 
the attention of the physician is more frequently directed to the occurrence 



ECTOPIC GESTATION. 549 

of primary rupture or abortion than to the existence of an ectopic gestation 
prior to this event. Too often efforts to arrive at a correct diagnosis may 
be the means of producing this catastrophe. Therefore, I would again 
emphasize the importance of delicate manipulation in a case of suspected 
ectopic gestation. Indeed, prior to the careful examination of a patient 
in whom an extra-uterine pregnancy is suspected it would be well to have 
ample provision for resort to immediate surgical procedure, in the event of 
collapse or rupture of the ectopic sac. Should the disaster occur during 
examination, or the physician be called upon to attend a case in which 
rupture had recently occurred, he should endeavor to keep the patient 
perfectly quiet and free from annoyance, with her clothing loosened. 
The foot of her bed should be elevated and a hypodermic injection of 
morphin should be administered not only to quiet the pain, but to lessen 
the nerve irritability and restlessness. An ice-bag should be applied over 
the abdomen, and immediate preparations made for opening the abdomen, 
in order to secure the bleeding vessel. The patient should be placed under 
the influence of an anesthetic. If the operator is at all in doubt whether 
the condition has resulted from an internal hemorrhage, he may confirm 
his suspicions by cleansing the vagina and making a puncture through the 
posterior fornix. This will permit recognition of the escaping blood. 
Indeed, through such a puncture the tubes may be examined and the pres- 
ence of the sac recognized. Moreover, a skilful operator may be able to 
secure the bleeding vesse^.s through the vaginal incision. Indeed, it 
has been advocated that the ruptured tube should be brought down, 
the surfaces cleansed, and sutures so introduced as to control the bleeding 
vessel and close the opening, leaving the tube in place. Such a plan of 
procedure is inadvisable, however. The fact that the caliber of the tube 
is so obstructed as to have caused an ectopic pregnancy would indicate that 
its retention must necessarily subject the patient to the danger of a recur- 
rence. With the abdomen opened, the bleeding vessel secured, and aseptic 
precautions, no great effort need be made to free the peritoneal cavity of 
blood, for, if the patient is kept under proper regimen, the blood is quickly 
absorbed and serves in some degree to sustain and support her. The abso- 
lute indication at this stage is to arrest the hemorrhage, and this is most 
effectively accomplished through an abdominal incision. As soon as the 
abdominal incision is made there will be a gush of blood. The pelvis will 
be found more or less occupied with blood-clot. Do not stop to turn out 
the clots, but proceed through the clotted blood to the fundus of the uterus 
and along either tube to discover the sac. The site of the gestation is 
recognized as a soft, boggy enlargement of varying size and consistency, 
according to whether the ovum is, or is not, in situ. The sac is brought up 
and examined for the rent. When the hemorrhage is marked, the broad 
ligament is clamped at once with forceps, the sac cut away, the cavity 
cleansed and ligatures applied. If the patient is profoundly anemic, no 
time should be lost in attending to the toilet of the abdomen, but it should 
be irrigated simply with normal salt solution to carry away the principal 
clots. 

The great majority of cases of ruptured ectopic gestation will recover 



550 GYNECOLOGY, 

without operation. The lowered vascular tension through the hemorrhage 
causes slowing of the current and favors the formation of a clot which 
plugs the vessel and arrests the bleeding. Experiments on dogs have 
shown that the ovarian arteries can be cut and left unligated and hemor- 
rhage will be arrested without the death of the animal. Taking these 
facts as premises, it has been concluded that in cases of profound shock, 
it will be wiser to defer steps to arrest the hemorrhage radically until the 
patient has rallied from the shock. The second premise does not take 
into consideration the difference between the human and the dog in the 
coagulability of the blood. As to the first, all abdominal surgeons know 
that women do die when a ligature slips from an ovarian artery, and too 
many cases of deaths from ruptured ectopic gestation sacs have occurred to 
make him feel easy while such a patient is in peril. He has no assurance 
that the revival of powers of the patient will not result in driving out the 
clot with which the vessel has been closed, so that where the conditions 
are favorable, the interests of the patient seem best served by an immediate 
operation. The operator should do the operation expeditiously and it 
would be well to have a simultaneous intravenous injection of normal 
salt solution to fill up the vessels. Time should be taken to wash out 
thoroughly the larger clots from the peritoneal cavity. The fluid blood 
diluted with salt solution will serve to sustain the strength of the patient. 
3. Treatment of the Patient Subsequent io Rupture, a. With intraperito- 
neal hemorrhage. The patient, having rallied from the shock, will in 
many cases recover without operative interference if she is kept per- 
fectly quiet, promoting drainage through the intestinal canal by frequent 
purgation, and limiting the amount of food and drink that is given. She 
is thus obliged to live upon her tissues, which will promote the absorption 
of even a large collection. As we have already seen, the tube which has 
been the seat of an abortion generally will be found distended with clots, 
and the same material will fill up the retro-uterine pouch. The convales- 
cence of the patient is usually shortened by the removal of the tube and the 
clotted blood. This is particularly true when the tube is the seat of a 
perforation from the villi, for frightful hemorrhage may be found, and 
under such conditions is likely to continue. Even when the hemorrhage 
arises as a result of rupture, we are not certain that the clot which plugs 
the vessels may not be loosened and a recurrence of bleeding follow. 
In spite of every precaution that may be observed it is not infrequently 
found that a collection of blood in the peritoneal cavity becomes infected 
from its proximity to the intestine, and thus a suppurative process is 
engendered which prolongs the patient's convalescence. Even this should 
not occur, if the blood-clot, becoming organized, causes thickening, ex- 
tensive adhesions, and more or less crippling of the function of the pelvic 
organs for the remainder of the patient's life. If the patient comes under 
observation some days subsequent to the evident rupture, thus affording 
sufficient time for the vessels to become occluded by clots, having an accu- 
mulation of blood in the pelvis, which frequently is walled off by plastic 
exudate from the general peritoneal cavity, the preferable procedure 
would be to make a free incision into the vault of the vagina. Two 



ECTOPIC GESTATION. 551 

fingers then should be introduced through this opening, the clots broken 
up and evacuated, the cavity thoroughly irrigated with normal salt solution 
and packed with iodoform gauze. Frequently the tube may be brought 
down and secured by ligature or clamp between the seat of rupture and the 
uterus, and thus the mass be removed. This is particularly true when 
the tube is occupied by a large blood-clot. When the tube is situated high 
in the side of the pelvis or in the lower part of the abdomen, in a position 
not readily accessible through the vagina, the abdominal incision is to be 
preferred. It affords a better opportunity to inspect the condition of the 
pelvic orgaris, to remove the occluded tube, and, if necessary, the associated 
ovary. It has been urged that where one tube has been the seat of an 
ectopic gestation which has ruptured and led to operative interference, the 
other tube should be removed likewise in order to prevent the possible 
occurrence of an ectopic gestation within it. The many cases in which a 
normal intra-uterine pregnancy has followed a tubal pregnancy would 
render such a course unwise. While numerous cases are recorded in which 
an operation for the removal of an ectopic gestation has been followed by 
the occurrence of gestation in the remaining tube, this, however, is not the 
rule. It would be just as logical to forbid matrimony because an 
occasional marriage is unfortunate. 

b. Extraperitoneal hemorrhage is a result of rupture of the tube be- 
tween the folds of the broad ligament. A hematocele is thus produced 
which is situated in the cellular tissue between the layers of the peri- 
toneum. The amount of hemorrhage is necessarily limited by the size of 
the vessel opened, the blood pressure, and the distensibility of the structure 
into which the hemorrhage has occurred. Where the collection is small, 
it may be sufficient to treat the patient expectantly, watch her progress, 
and trust to nature to absorb the exudate. Even so, it is possible, in rare 
cases, for the embryo to survive the accident and continue to grow. The 
continuation of the growth of the fetus presents additional and more 
serious problems. Prior to the fourth month the embryo, tube, ovary, and 
adjacent portion of the broad ligament, including the placenta, can gener- 
ally be removed. Subsequent to this period, however, the placenta may 
nave attained such a size as to render its removal difficult. Not infre- 
quently the life of the patient is endangered by a subsequent rupture. 
The placenta extends upon the pelvic surface, covering over and surround- 
mg the vessels and the ureter. Moreover, the intestines may aid in form- 
ing the sac wall of the developing embryo and a condition result which 
would render any operative interference exceedingly serious. Where the 
patient shows marked symptoms of internal hemorrhage and an exami- 
nation reveals a collection of large size, an immediate operation is prefer- 
able, for the depressed condition of the patient increases the danger of 
infection of the effused blood from the walls of the adjacent intestine. 
When infection enters the sac, suppuration will follow. This, of course, 
greatly endangers the life of the patient. With such a collection, early 
interference is preferably made through the abdomen, for the reason that 
it affords a better opportunity for exposing and securing the bleeding 
vessel. Having opened the abdomen, the peritoneal cavity so far as 



552 GYNECOLOGY. 

possible should be carefully walled off with a large quantity of gauze^ the 
blood-clots evacuated, and the bleeding vessels searched for and secured. 
If the blood collection has been a large one and the pelvis is covered with 
adherent blood-clot, an opening should be made into the vagina, through 
which should be carried the end of a piece of gauze sufficient to fill the 
cavity. When the collection has been extraperitoneal, the abdomen can 
be walled off with gauze before the broad ligament is opened, the clots 
should be turned out; the bleeding vessel secured; the cavity packed with 
gauze, the end of which has been carried through an opening in the vagina, 
thus allowing the peritoneal wound to be closed. Care must be exercised, 
however, in this procedure not to injure the uterine artery or the ureter. 

4. Method of Treatment Advisable in Advanced Growth of the Embryo. 
a. The child alive. From the fourth month to the completion of pregnancy 
the existence of a quick placenta presents a condition which is generally 
regarded as the most dangerous in the whole realm of surgery. The sac 
has ruptured, the placenta has formed new and more extended attach- 
ments. While the condition of the patient cannot be considered other- 
wise than grave, the immediate danger is not so great but that we can afford 
to wait until a later stage of the pregnancy for interference and thus give 
the fetus a chance for its life. 

The existence of the live placenta and the profound hemorrhage which 
results from any effort at its removal have led many operators to question 
the advisability of operative procedure while the child is alive. Some 
have advocated either to secure the death of the child by injecting into its 
body poisonous materials, such as morphine, or when near the completion 
of the pregnancy to await its death. They have justified this course of 
action by the assertion that in the great majority of cases the product of 
ectopic gestation is puny, ill developed, and often malformed — even when 
it survives extraction it usually lives but a few weeks, or at most months. 
Therefore they claim that the life of the mother should not be endangered to 
insure the life of a defective child. Experience, however, has disclosed 
that the extra-uterine fetus may be well developed, and when it is evident 
that the mother can be saved only by operative procedure, it seems coward- 
ice that this should not be employed at a stage that will give the other being 
an opportunity for continued existence. Fortunately, the investigations 
of Dunning have demonstrated that the maternal chances are increased by 
operation during fetal life. The recognition of extra-uterine pregnancy, 
then, should lead to the preparation for operation at a certain definite 
time prior to the completion of the gestation, preferably at about eight and 
one-half months. 

In resorting to operative procedures we must consider two points: 
I. How to treat the sac; 2. How to dispose of the placenta. The 
sac is composed of remnants of the expanded tube or of the broad 
ligament, thickened and in parts expanded. In some places coils of in- 
testine or the adherent omentum also enter into its formation. The re- 
moval of the sac, consequently, is fraught with danger, not only to the 
adjacent 'arge blood-vessels and ureters, but to the abdominal viscera in 
general. When the pregnancyhas passed the fifth month with ample evi- 



ECTOPIC GESTATION. 553 

dence of a living child, I would advise that interference be postponed until 
after the eighth month. It should be undertaken, however, not later than 
at eight and one-half months, in order to afford the fetus the best chance 
for its life. 

The operator is compelled to adapt his procedure to the condition 
immediately confronting him. The position of the fetus has been recog- 
nized and carefully outlined. In the majority of cases the median incision 
affords the best opportunity for the delivery of the fetus and the manage- 
ment of the sac and placenta. Having entered the peritoneal cavity, the 
sac is carefully examined and efforts made to avoid injuring the placenta. 
Where the sac is situated in front, we should endeavor to open it on one side. 
After opening the sac the most available part of the fetus is seized and de- 
livered quickly. The cord is clamped with two hemostats and cut be- 
tween them. The fetus is then removed and given to an assistant to be 
cared for. This preliminary discussion presents the question i. How 
to treat the sac. The sac is composed of remnants of the distended tube 
or the broad ligament, thickened and expanded in parts. In other 
places coils of intestine or portions of the adherent omentum assist in 
forming it. The removal of the sac, consequently, is associated with 
great danger, not only to the adjacent large blood-vessels, but to 
the viscera and ureters. The ideal plan, where possible, is to follow 
the delivery of the fetus by the removal of the sac, including the placenta; 
where the removal of the sac cannot be safely accomplished, the operator 
should stitch its edges to the skin margins of the abdominal wound. In 
well-advanced pregnancy we may possibly be able to push the peritoneum 
from the anterior abdominal wall and to penetrate the sac without opening 
the peritoneal cavity, but the chief difficulty would be to determine then 
2. How to dispose of the placenta, which will depend entirely upon its situa- 
tion. Its management is most promising when situated in the pelvis be- 
low the fetus. When above the fetus, the placenta may be injured and 
result in furious bleeding or, indeed, death of the patient. Even prompt 
seizure and ligation of the uterine side of the sac may fail to arrest the 
bleeding. The abdominal aorta may then be compressed, the cavity 
packed with sponges, and an application made of perchlorid or per- 
sulphate of iron. The danger of bleeding has frequently induced surgeons 
to leave the placenta and allow it to slough away, employing proper meas- 
ures for securing external drainage. When the removal of the placenta can 
be accomplished without too much risk, it should be done. In addition 
to avoiding the placenta in opening the fetal sac, we should exercise the 
precaution to prevent discharge of the amniotic contents into the peri- 
toneal cavity. After delivery of the fetus the operation is completed in 
one of three ways: 

3 a. Extirpation of the entire sac; b. Removal of the placenta with- 
out the sac; c. Retention of the placenta and sac. 

a. Extirpation of the Entire Sac. Whenever it can be accomplished 

safely, the entire sac should be removed. As this operation is complete 

convalescence is surer. Removal can be accomplished when we can 

■ construct a pedicle and the sac wall is made of tissue that can be removed 



554 GYNECOLOGY. 

without disadvantage. The pedicle may be narrow or broad as in an 
ovarian cyst. 

b. Removal of the Placenta without the Sac. The placenta should be 
removed whenever it can be separated without hemorrhage, or when it is 
so situated that the vessels supplying it can be ligated securely and the 
mass removed, or when its position is such that effective control of hemor- 
rhage can be accomplished by tampons of iodoform gauze. After re- 
moval of the placenta the gauze may be removed and replaced by a large 
drain. 

c. Retention of the Placenta and Sac. When the placenta is firmly 
attached or it is evident that its detachment would result in dangerous 
hemorrhage, it should not be disturbed. The operator should exercise 
the greatest care in the management of the live placenta, as hemorrhage in 
such cases is frightful and exceedingly difficult to control. Where the 
placenta is partially detached, it may be necessary to proceed with its 
removal. This should be accomplished quickly, making firm pressure over 
the parts with iodoform gauze. If the attachment is of a character to 
permit it, the parts should be quilted together by a ligature which is tied 
firmly around the base of the placenta. Where it is necessary to retain 
the placenta and the sac, one of the following methods can be practised : 
The sac can be fixed to the abdominal wall and the cavity drained ; or the 
opening in the sac can be closed, covering over the placenta and shutting 
off the latter from the general peritoneum. The cord should be cut off 
close to the placenta, after previous ligation with chromic catgut, or its 
vessels can be closed by the electro-angiotribe. This instrument appeals 
to me as an efi&cient means of controlling hemorrhage and insuring the 
removal of a portion of the placenta. To accomplish this, it will require 
a modification of the angiotribes at present in use, employing one with a 
more flattened surface, thus allowing a good portion of the placenta to be 
subjected to the slow action of heat. The placenta and sac should be 
closed and returned to the peritoneal cavity only when we have been 
able to secure absolute and rigorous antisepsis. Microbic infection may 
lead to putrefaction of the placenta and suppuration. The disadvantages 
of the retention of the placenta are that its separation and discharge are 
tedious and present continuous risks of septicemia and peritonitis. Fecal 
fistula may form. These risks are decreased by irrigation of the sac, by 
the ligation of the cord close to the placenta without disturbing the latter, 
by carefully sponging the cavity, and then, as has been suggested, by her- 
metically closing it. Even though we are able to exclude germs from the 
cavity, it must be remembered there is danger of their entrance through 
adhesions to the intestines. Intestinal micro-organisms may gain access 
to the placenta and produce decomposition. The following rules have 
been formulated by Sutton : 

When the placenta is situated above the fetus, attempt its removal. 
If the placenta has become partially detached during the course of the 
operation, no choice is left but its removal. 
The placenta below the fetus can be left. 
If the placenta is left, the sac closed, and subsequently symptoms of 



ECTOPIC GESTATION. 555 

suppuration occur, the wound must be laid open at once and the placenta 
removed. 

h. The Fetus Dead, Mummified, or Reduced to a Lithopedion. The 
death of the fetus at any stage results in early arrest of the circulation in 
the placenta. The continuation of the growth of the placenta after the 
death of the embryo has been considered as a possibility, but this is very 
improbable. The placenta does not decompose, but undergoes slow and 
complete atrophy. The vessels in the maternal portion atrophy and dis- 
appear. This, consequently, leaves much less of the placental structure 
than would be found in an extra-uterine pregnancy. The absorption 
of the placenta continues until, in those cases in which the lithopedion is 
formed, the placenta is found to be entirely absent. Should the patient 
come under observation when the history would lead us to suspect that the 
fetus has but recently perished, it would be wise to postpone operation a 
few weeks later, when arrest of the circulation in the placenta may become 
complete. The sac is exposed by the abdominal incision, the general 
peritoneal cavity is well protected by gauze packing, and every care exer- 
cised to prevent the contents of the sac from soiling the peritoneum. This 
danger will be decreased greatly by drawing off the contents of the sac with 
an aspirator, and guarding the peritoneal cavity carefully with sponge 
packing before the sac is opened. The fetus is withdrawn and the sac 
examined then with a view to its removal, if possible. Where the condi- 
tion will admit, the entire sac, with the enclosed placenta, should be re- 
moved. If knuckles of intestines are adherent to the sac, the greatest 
care should be exercised in their separation, in order to avoid inflicting 
injury to them. Where the adhesion is firm, the separation should be 
made at the expense of the sac wall, leaving a portion of it attached to 
the intestine. When a large portion of the intestine enters into the 
formation of the sac wall, the removal of the sac will not be feasible. In 
such cases the placenta should be peeled out, the cavity thoroughly 
sponged with carbolic acid and afterward with alcohol, dried, packed with 
gauze, and its edges stitched to the abdominal wound. Where the sac 
is dependent and in close approximation to Douglas' pouch, an opening 
should be made through its base into the vagina, through which drainage 
may be effected and the upper part of the sac closed. Vaginal drainage 
of the sac should be employed whenever possible, as the drainage is from 
the most dependent portion and the convalescence of the patient is much 
shorter and the dangers of subsequent ventral hernia greatly decreased. 
Following the death of the fetus marked changes occur. The fetus itself 
may become mummified, forming a flattened mass, when its watery 
portions are absorbed. The entire fetus undergoes a substitution of fat 
for its original structures, forming a lardaceous condition; or, the fetus 
and its sac undergo calcareous degeneration and forms a rather dense, 
hardened mass. Some of these conditions may continue for years. A 
lithopedion has been found in a woman of ninety. Its presence, however, 
always predisposes to infection, which may result in suppuration, with 
subsequent discharge of particles of the calcified mass. Wherever possi- 
ble, the entire mass should be removed. After an abdominal incision, 



556 GYNECOLOGY. 

wherever it is recognized that the mass has formed extensive adhesions 
to the intestines and other structures of such character as to preclude the 
probability of successful removal, the sac should be opened, its contents 
removed so far as possible, the sac wall stitched closely to the abdominal 
wound, and its cavity packed with gauze. The removal of the fetus and 
the drainage of the sac result in its complete obliteration and the restora- 
tion of the patient to health. 

c. Following Decomposition of the Fetus and Suppuration of the Sac. 
Decomposition of the fetus and suppuration of the sac are indicated by 
symptoms of inflammation, the sac becoming tender to pressure with 
evidence of localized peritonitis. The temperature of the patient will 
be elevated; possibly recurring chills, night-sweats, progressive emacia- 
tion, and symptoms of low continued fever will be manifest. Lique- 
faction of the sac by pus-formation causes thinning and even rupture of 
its walls, with the escape of its contents into the peritoneal cavity, the 
bladder, the intestine, the vagina, or through the abdominal walls. The 
rupture results in the formation of a sinus, through which fragments of 
small fetal bones often will be found passing. The existence of suppura- 
tion should be considered an indication for immediate operation. 

To open the sac without entering the peritoneal cavity is, of course, 
more satisfactory, and occasionally this can be accomplished. If the 
adhesions between the peritoneal surfaces are not extensive, the opening 
may be a small one. The adhesions may be extended by gauze packing 
and other means. Where parietal adhesions do not occur, the sac should 
be opened and its contents thoroughly evacuated, but the peritoneal 
cavity must be thoroughly protected from soiling by gauze packing. 
Every fragment of bone should be removed, for otherwise the obliteration 
of the sac will not take place and suppuration will continue as long as the 
irritation remains. The cavity of the sac should be thoroughly packed 
with iodoform gauze and the sac itself be stitched to the skin edges. 
During the convalescence the cavity should be irrigated frequently with 
antiseptic fluids. Sometimes we may be able, especially where the open- 
ing has taken place through the abdominal wall, to dilate the sinus and 
empty the sac without opening into the general peritoneal cavity. This 
method of procedure can be used effectually in the opening through the 
abdominal wall and the vagina, but openings into the bladder or intestine 
will require abdominal operation. However, efforts should be made to 
remove the sac, if possible, and to close the intestinal or vesical openings. 

GENITAL TUMORS. 

276. Genital Tumors. In the broad sense of the term any unusual 
swelling or protuberance of a part can be called a tumor, but the designa- 
tion is properly restricted to a new-growth which is neither produced 
by inflammation nor productive of it. Such a growth is distinctly cir- 
cumscribed, has a marked course, can be definitely differentiated, and is 
associated with febrile symptoms only when degenerative changes exist. 

Classification. Tumors of the genitalia, like those occurring in other 



GENITAL TUMORS. 



557 



portions of the body, are divided clinically into the benign and malignant; 
pathologically into neoplasms and cysts, and histologically into those 
which originate in adult or in embryonic tissues. The following table, 
prepared for me by Dr. P. B. Bland, presents the subject in a readily 
comprehensive form: 

Fibroma 

Myoma 

Fibromyoma 

Fibro-adenoma 

Angioma 

Lipoma 

Myxoma 

Chondroma 

Osteoma 



Adult connective tissue 



Benign 



Solid 



. Adult epithelial tissue 



Neuroma 
Papilloma 
Adenoma 



Cystic 



f Retention 

1 Glandular ^ jy^^^^-^^ 

Papillary keratoma 

[ Congemtal p^.^^^.j^^ 

[ Vaginal cysts 



cj { Embryonic epithelial tissue. 



Malignant 



jig f Embryonic connective tissue 



f Carcinoma 
Chorio-epithelioma 
malignum 

J Sarcoma 

\ Endothelioma 



When we come to analyze the arrangement of these growths into 
groups, we find that any arrangement must be more or less arbitrary. 
The transition from one form to another is so subtle as to make the 
classification of some growths very difficult and uncertain. The defini- 
tion into benign and malignant is of classic origin and necessarily of great 
importance. A benign tumor may be defined as one which in the course 
of its development inclines to remain local or confined to the structures in 
which it originated. It develops from adult tissue, is not usually destruc- 
tive to life in its progress, and displays no disposition to metastasis nor to 
recur when removed. The malignant tumor, on the contrary, is supposed 
to have its nidus in embryonic tissue, gradually breaks down its original 
barriers, invades the surrounding structures, extends by metastasis until 
the entire organism may become infected, and displays a marked tend- 
ency to recur after surgical intervention. 

The study of the structure of growths shows a marked difference in 
the cellular tissue of the two classes, each having well-defined tissue 
changes which render them recognizable, and from which the future 
progress may be predicated. 

In the differential diagnosis it is often difficult to draw the line and 
assert that the benign terminates here and the malignant begins there. 
In some of the uterine and ovarian growths, particularly the glandular 



558 GYNECOLOGY. 

varieties, we are forced to rely upon the life history of the growth in 
order to determine its proper classification. Notable examples are the 
glandular and malignant adenomata of the uterus and the papillomata of 
the ovary. 

277. Characteristics of Benign Neoplasms. The benign growths 
have been divided into solid and cystic, and the former, from their 
structure, into the connective-tissue and the epithelial tumors. The 
connective-tissue growths predominate among the benign, and while 
they may be found in all the tissues of the genitalia, they characterize 
to the greatest degree those springing from the uterine parenchyma. 
They are known as the myomata or fibromyomata, according as the 
muscular or connective tissue predominates, or the fibromyomata in a 
combination of the two. Cystic tumors are those which consist of the en- 
velope, sheath, or sac containing thin serum, blood, pus, mucin, sebaceous 
material, parasites, hair, cartilage, or bone. These tumors have their 
origin in the ovaries, broad ligaments, vulva, and vagina, in congenital 
remains, as the Wolffian bodies, the parovarian and remnants of the ducts 
of Gartner, and the Miillerian ducts. 

Cystic growths of the ovary present considerable difficulty in classi- 
fication, inasmuch as twenty per cent, of them prove to be malignant. 
Even careful microscopic examination of the growth will not always aid 
proper classification, because a malignant nodule or portion may be en- 
grafted upon what otherwise seems a benign growth, and may be so situated 
as to escape observation, for the examiner would be entirely unable to 
subject the parts of a large growth to such an investigation. Certain 
of these growths — the papillomatous variety — show a disposition to grow 
through the enveloping sheath or cyst wall, and when it is ruptured, their 
contents even infect or become implanted upon the peritoneal surface, 
causing a low grade of peritonitis and an extensive ascites. Such behavior 
at once answers to the description of malignant disease, but experience 
demonstrates that in the majority of cases the removal of the original 
source of infection, the ovarian growth, produces atrophy and disap- 
pearance of the secondary infection of the peritoneum. In many of these 
growths the surgeon is compelled to determine the final diagnosis between 
benignancy and malignancy by the subsequent clinical history of the 
patient. In discussing specific growths, comparison can be made more 
readily by considering separately the tumors, benign or malignant, 
which are prone to occur in each portion of the tract. 

In the former editions I discussed some conditions under genital 
tumors, using the term in its unrestricted sense, which I will now consider 
separately. These conditions are hernia, hydrocele, varicose veins of 
the vulva, edema, elephantiasis, and urethral caruncle. 

278. Hernias. The gaseous cysts are hernias which present in the 
vulva two varieties — the anterior labial or inguinal, and the posterior 
labial. The anterior labial hernia is analogous to the scrotal hernia in 
the male. It is formed by a portion of intestine or omentum descending 
through the inguinal canal and distending the large labium. (Fig. 462.) 
This form of hernia is comparatively rare in women. Femoral hernia is 



GENITAL TIBIORS. 



559 



much more frequent in the female. In the latter the hernial sac emerges 
below Poupart's ligament and makes its exit as a lump in the groin, which, 
as it increases in size,, pushes up over the ligament. In the sac of an in- 
guinal hernia has been found an ovary and tube and even the fundus of 
the uterus. Instances have been recorded of an ovarian cyst or a tubal 
gestation complicating such a hernia. The posterior labial hernia (Fig. 
463) is formed by the intestine driving the peritoneum through the pelvic 
aponeurosis and the levator ani muscle. The sac appears at the side of 




Fig. 462. — Anterior Labial or Inguinal Hernia. 

or projects through the vulvar orifice. Labial hernia may sometimes be 
difl&cult to differentiate from hydrocele or a fatty tumor of the labium. 
A double hernia with an ovary in each labium associated with a large 
penis-like clitoris may cause some doubt as to the sex of the individual. 
279. Hydrocele. A well-formed serous cyst which is continuous 
with the peritoneal cavity is sometimes situated in either labium majus, 
or when the canal of Nuck is patulous it may, by slight pressure, be emp- 
tied back into the peritoneal cavity to recur as soon as the patient assumes 
the upright. This tumor is known as hydrocele, and is analogous to 
the serous collection sometimes found in the scrotum of the male. The 



56o 



GYNECOLOGY. 



sac is thin walled, quite translucent, and affords a distinct sense of flue 
tuation. The swelling gradually increases in size and may become so 
large that it is uncomfortable in sitting or walking, and may prove an 
obstacle to the sexual relation. Hydrocele is readily distinguished from 
solid tumors by its translucency and distinct fluctuation; from hernia by 
its being more continuously distended, except in the few cases in which 
the canal of Nuck remains patulous, the more distinct sense of fluctua- 
tion, its translucency, a less amount of pain or discomfort, the absence 




Fig. 463. — Posterior Labial Hernia. 

of any swelling over the line of the inguinal canal, and the failure of the 
protrusion to increase during coughing or straining. 

Treatment. The contents can be removed readily by puncture, but 
recollect rapidly. Obliterative inflammation may be engendered after 
the removal of the fluid by the injection of some irritating agent, and 
pressing it about to bring it in contact with the entire cavity of the sac, 
but care must be exercised to prevent its being forced through an open 
canal into the peritoneal cavity. A safer and more satisfactory procedure 
will be to make a free opening into the sac and pack it with iodoform 
gauze,. 



GENITAL TUMORS. 56 1 

280. Urethral Growths. Erectile or vascular tumors are rare in 
the labium, but when they occur, present characteristics similar to those 
in other portions of the body. Vascular growths about the urethra are 
much more frequent. 

Pozzi states that the hymen is not a simple isolated structure surround- 
ing the vulva, but comprises, first, the masculine frasnum vestibuli; second, 
the ring inclosing the urinary meatus; and, third, the hymen. The struc- 
ture is the undeveloped matrix tissue of the corpus spongiosum in the male, 




Fig. 464. — Urethral Caruncle. 

and has not become erectile. These considerations, he asserts, throw 
light upon the origin of some of the vascular growths of the urethra and 
meatus. The retention of the erectile tissue in the female, which is 
normal in the male, results, through efforts at micturition, in the forma- 
tion and extrusion of a polypus, known as a urethral caruncle. 

A urethral caruncle appears as a bright red, fragile looking projection 
from the urethral orifice. It is largely composed of dilated capillaries 
with a small amount of connective tissue, and is covered with pavement 
epithelium. Microscopic sections of these growths have revealed the 
presence of well-marked glandular structures. The growth is amply 
36 



562 



GYNECOLOGY. 



supplied with nerves, which are more or less exposed. The structure 
of the growth accounts for its vascularity and great sensitiveness. (Fig. 
464). ^ 

Etiology. Caruncle may occur at any age. Often seen in young 
children, it is more frequent in middle life, and has been found in women 
as late as the seventy-fifth year. It occurs with equal frequency in the 
married or the unmarried. 

Symptoms, The growth usually projects from the meatus and 
generally is situated on the posterior urethral wall. When the vulva is 




Fig. 465. — Prolapsus Urethra. 

separated widely, the tumor is pushed forward and rendered more prom- 
inent. Its sensitiveness varies in different individuals. In some it 
produces no marked symptoms, while others complain of continuous 
burning, a sensation of fullness in the urethra, and marked pain during 
and for several minutes following urination. Occasionally the distress 
is so marked that the act of micturition is prevented and the employment 
of a catheter is rendered necessary. As extreme sensitiveness frequently 
causes it to be a barrier to the sexual relation, it is one of the causes of 
dyspareunia. 

Diagnosis. The tumor is readily recognized by its bright red ap- 



GENITAL TUMORS. 



563 



pearance, extreme sensitiveness, and fragility. A varicose condition of 
the urethral vessels may occur, but this is characterized by bluish projec- 
tions from the urethral orifice, which are plainly recognized as distended 
veins, somewhat resembling hemorrhoids about the anus. A prolapse 
of the urethra may exist, but this condition forms a rounded projection 
which partly or completely encircles the urethral orifice. (Fig. 465.) 
Treatment. The only treatment that affords any hope of succ'ess is 
excision. This may be done under cocain anesthesia. The mass is 
picked up and cut off at its base with scissors, and bleeding arrested by 
coaptating the surfaces with a suture. It is more satisfactorily accom- 




FiG. 466. — ^Varicose Veins of the Vulva. {Dr. W. Krusen.) 



plished, however, under general anesthesia, as the patient is then quiet 
and the manipulation can be more deliberate. The excision of the mass 
with scissors and the application of the thermocautery to the base are 
very efficient. In the employment of the thermocautery a wooden rod the 
size of a catheter should be introduced previously to preserve the urethra 
from destruction. Especial care must be exercised to control the hemor- 
rhage, as I have seen frightful bleeding occur from such an operation. 

281. Varicose veins of the vulva are not infrequent during gesta- 
tion. (Fig. 466.) Holden reports a case in which the labia majora 
were the size of a fetal head. The patient died of phlebitis. The tumor 
presents a bluish color on the surface of the integument, violet on the 
mucous surface, and causes a sensation of weight in walking or when the 
patient is upright. The rupture of such a tumor may cause serious or 
even fatal hemorrhage. The patient should be cautioned to wear 
loose clothing, with no constriction about the waist. The varicose parts 



564 GYNECOLOGY. 

should be supported. The most effective treatment is excision of the 
principal veins. 

282. Edema. Anasarca is frequently accompanied by extensive 
swelling of the labia. The cause is readily recognized by the associated 
condition. When edema exists without general dropsy, it is indicative 
of some obstruction to the circulation in the pelvis. Edema confined to 
one labium is generally the result of injury or inflammation. A hard, 
dense exudation in one labium will usually be found to be due to a hard 
chancre, situated upon the same side at the margin of the vagina. 

283. Elephantiasis consists in chronic inflammation of the lymphat- 
ics, with dilatation of their canals. It is very rare in our climate, but 
is more likely to exist in hot climates. The cause of the condition is 
unknown. The affection consists of more or less considerable hypertro- 
phy of the entire vulva, sometimes localized in certain regions, as, for ex- 
ample, in the clitoris. The large hypertrophied labia form voluminous 
masses, which may exceed the dimensions of an adult head. (Fig. 468.) 

Three forms are described: i. the entire derma is hypertrophied, with 
vast dilatation of the lymph-spaces; 2. the engorgement of the lymph 
in the capillaries and large trunks; 3. the lymphatic ganglia become the 
seat of fibrous alteration. 

Symptoms. The enlargement is frequently so great that walking and 
urination are interfered with. Friction of the surface leads to ulceration, 
which is slow to heal. The thickened tissues invade the vulva and the 
perineal and anal regions, and form enormous tumors. When the surface 
of the skin is smooth, it is called glabrous; when roughened, with warty 
projections, verrucous; and papillomatous when the papillae are much 
hypertrophied. 

Diagnosis is easy. The hypertrophy and swelling of lupus are always 
accompanied by ulceration. The papillomatous vegetations are situated 
directly on the skin. In fibromata and myxomata which become ped- 
unculated the tumors are isolated and circumscribed, while elephan- 
tiasis is diffuse. The cause of the condition is unknown, although it 
has been attributed to syphilis. It is due to an acute lymphangitis, with 
intense fever. The only effectual treatment is ablation and the suturing 
of the surface in order to secure union by first intention. 

THE VULVA. 

284. Tumors of the vulva are comparatively rare and comprise cystic 
and solid, benign and malignant, growths. 

285. Cysts. Serous cysts would naturally be expected to occur in a 
region so well provided with glands as is the vulva. Retention cysts of 
the gland of Bartholin belong to this class. (See Bartholinitis sec. 234.) 

Sebaceous cysts rarely attain to any size. They are found upon the 
labia majora, the labia minora, in the sulcus between them, about the 
clitoris, over the mons veneris, and sometimes upon the edge of the 
hymen. 

Blood cysts are occasionally found. These may originate in a preex- 



GENITAL TUMORS. 565 

isting hematoma, through a hollow, round ligament (Koppej, in the sac 
of an old hernia, in the site of a thrombus, or from dilatation of lymph- 
vessels. 

Cysts are also found in the hymen — Doderlein says, from fusion of 
adjoining surfaces; in the urethra, either from obliteration of Skene's 
glandules or the dilatation of a terminal and unobliterated vestige of 
Gartner's duct. 

Hematoma of the vulva and vagina has been described. (Sec. 271.) 

Abscess. (Sec. 234.) 

Neuroma of the vulva is a rare condition. Painful nodules are oc- 
casionally recognized, and their presence occasions vaginismus. 

Treatment would be to excise painful spots. 

286. Simple Vegetations. Vegetations appear upon the vulva in the 
form of papillomata or condylomata, occasionally having the appearance 
of a cauliflower. They may be situated at the edge of the vulva in isolated 
projections, or may cover, by a voluminous growth, the whole surface of 
the external genitalia. The mass may extend backward around the anus, 
and may attain the size of a fetal head. The vegetations present a pale 
red color, often a deep wine tint, and are situated upon the vulva, peri- 
neum, and margin of the anus, sometimes extending forward over the 
mons veneris and over the inner surface of the thighs. (Fig. 467.) A 
profuse leukorrheal discharge is generally present, which is retained by 
these vegetations, and causes an extremely disagreeable and fetid odor. 
The decomposing discharges irritate the surface, which becomes greatly in- 
flamed during walking and exercise. They are generally considered an in- 
dication of venereal infection, and are produced by either gonorrheal or 
syphilitic virus. (Fig. 468.) Transmission of the disease by contact 
has been observed. The presence of vegetations, however, is not always 
an indication of specific infection, as these growths arise in pregnant 
women from a simple leukorrhea. The surfaces upon which they are 
implanted may become thickened by inflammation, undergo ulceration, 
and be covered by a glairy, fetid mucus which increases the resemblance 
to malignant disease. A vertical microscopic section of a growth, how- 
ever, will reveal its true character. In the vegetations are dilated, treelike 
capillaries embedded in connective tissue, and covered with several layers 
of epithelium, thus presenting a marked contrast to the nests or tubular 
masses of epithelium embedded in connective-tissue stroma, which indicate 
the presence of epithelioma. 

Treatment. Keep the parts thoroughly clean, irrigate with bi- 
chlorid solution (i : 2000), and dust the surface with equal parts of alum 
and sugar or paint it with carbolic acid and afterward wash with alcohol. 
When the vegetations are very extensive, the most eft'ective method 
of treatment is to place the patient under an anesthetic and cut away 
the vegetations with scissors, cauterize the base with nitric or chromic 
acid, or, still better, with the thermocautery, and subsequently keep the 
parts clean and dusted with a drying powder. Convalescence will be 
rapid. The existence of pregnancy need be no barrier to the method 
of treatment indicated, as the danger to the patient from sepsis following 



566 



GYNECOLOGY. 



delivery is much greater than any which could result from removal of 
the growths. 

General anesthesia can be avoided by saturating the parts with a lo 
per cent, solution of cocain. Removal of the growths by the curet has 






Fig. 467. — ^Vulvar Vegetations. 

been advised, but the scissors affords a cleaner and more effective instru- 
ment. Excision produces less irritation of the subjacent skin. The 
hemorrhage may be controlled by the application of a strong solution 
of^^persulphate of iron, but the thermocautery will prove more satisfactory. 
The burning of the latter can be lessened by painting the surface with 




Fig. 468.— Vulvar Vegetations from Syphilitic Infection. 



GENITAL TUMORS. 



567 



carbolic acid or better still by the application of a compress wet with a 
5 per cent, solution of carbolic acid. The application of a 10 to 40 per 
cent, solution of formaldehyd two or three times will cause the vegetations 
to slough, but this is a painful application. 




Fig. 469. — Elephantiasis of the Vulva. 

287. Fibroma and myxoma are tumors which are found in the large 
labia, though they may also develop in the nymphae or in the perineum. 
They are benign tumors of slow growth, though they occasionally attain 
to large size. The former become pedunculated. The tumor may be 
enucleated or the pedicle may be cut without danger of hemorrhage. 



568 GYNECOLOGY. 

Fig. 470 shows a fibroid tumor that occurred in the practice of Dr. S. 
E. Cox, of Nashville, to whom I am indebted for the illustration. 

288. A lipoma is a fatty tumor of the labium which may resemble 
elephantiasis. Through the kindness of Dr. E. L. Reed, of Atlantic 
City, I was permitted to remove a lipoma the size of an orange from the 
vulva of a woman who consulted him because she feared it was a hernia. 
Lipomata are usually small, but Stiegel removed one that weighed ten 
pounds. 

289. An enchondroma is an exceedingly rare cartilaginous tumor 
which affects the clitoris. It may become as large as the fist and present 

calcified portions. Bartholin reports a 
Venetian courtesan who wounded her 
paramour with her ossified clitoris. 

290. Malignant Disease of the 
Vulva. Malignant disease occurs in the 
vulva in the form of epithelioma, sar- 
coma, and in rare cases as adenocar- 
cinoma. Primary cancer of the vulva 
is rare. Epithelioma is the most fre- 
quent form and begins in the large 
labium or in the cleft between it and the 
lesser labium, less frequently in the 
clitoris or the meatus. The disease 
originates from the squamous epithelium 
and usually appears first as small warty 
nodules covered with thick layers of 
epithelium. Sometimes it follows irri- 

FiG. 470. — Fibroid of Labium. , ,• 1,^.^1.1. r •• • i* 

' tation about the base of a preexistmg 

papilloma or wart. It is frequently preceded by psoriasis. The epithe- 
lium covering the nodules undergoes degenerative changes and causes a 
discharge of thin watery fluid mixed with blood. Groups of the embry- 
onic cells fracture the limiting membrane and penetrate deeper tissues, sup- 
planting the normal tissue and forming the characteristic epithelial pearls. 
Sometimes the cells will be found in the act of penetrating the walls of 
the blood-vessels, thus expediting the propagation of the disease. As 
the infiltration advances, superficial ulcerations occur, which gradually 
become deeper and involve the neighboring structures. (Fig. 471.) 
The superficial inguinal glands are the first to become infiltrated with the 
malignant cells. The disease occurs upon one side and then spreads to 
the opposite, possibly by inoculation through apposition. Adenocarci- 
noma results when the disease begins in the glands of Bartholin. 

Sarcoma occurs in the simple form as melanosarcoma. 

Symptoms. The patient suffers from intense pruritus, in scratching 
for which the nodules, previously unnoticed, are discovered. These 
become excoriated and cause a bloody discharge and an exceedingly fetid 
odor; not infrequently the nodule is a wart which has become irritated at 
its base and subsequently infiltrated. The nodules may be sessile or 
pedunculated, and subsequently coalesce. When the disease occurs 




GENITAL TUMORS. 



569 



about the urethra, the orifice may become contracted, and the canal may 
appear as a hard, indurated cyHnder. The ulceration presents excavated 
borders, with the adjacent skin infiltrated and hard, and the pubic hair 
may fall out. In the later stages the skin and tissues for some distance 
around the vulva become indurated and hard, and the glands of the 
groin are infected. With the extensive inflammation, the discharge, 
loss of blood, loss of rest, and the mental anxiety cause emaciation, and 
death follows from marasmus, sepsis, or metastatic development. The 




Fig. 471. — Cancer of the Vulva. 

latent period is a long one, the disease remaining for some length of time 
with but slight circumjacent or more extensive involvement. Death 
occurs in the second or third year. 

Diagnosis. The history of continued genital psoriasis; intense pruritus, 
with small nodules; arrangement of the epithelial layer, which shows a 
tendency to break down; the irregular ulceration, with infiltrated base 
and margins; and, later, glandular involvement, are sufficient to indicate 
the character. Papillary vegetations extend over a cons derable sur.ace^ 
are comparatively free from induration, and in no sense resemble cancer. 
A polypus or caruncle of the urethra has a base free from induration. 
Chancre is an indurated sore without disposition to spread, and is as_ 



570 



GYNECOLOGY. 



sociated with glandular involvement, and later with syphilitic eruption. 
Chancroid is a superficial ulceration without induration. The contiguous 
surfaces readily become inoculated. The lymphatic glands promptly 
go on to suppuration and to the formation of buboes. In lupus the ulcera- 
tion is serpiginous, with a tendency to cicatrization in the tissues first 
affected, and glandular involvement is rare. 

The prognosis of malignant disease of the vulva is bad. The cases 
usually come under observation after extensive involvement, generally 




Fig. 472. — ^Appearance of the Vulva after an Operation for Cancer of the Vulva. 



after the lymphatic system has become invaded by the malignant process. 
Operative treatment delays the progress of the disease and renders the 
patient more comfortable. 

Treatment. The only hope for the patient consists in total removal 
of the disease. Some prefer the thermocautery or galvanocautery to the 
knife, as affording less danger from secondary inoculation. The scissors 
or the knife, however, are preferable, as by their use we shorten the con- 
valescence and leave the structures less distorted. Care must be exer- 
cised, when possible, not to injure the meatus. In peri-urethral cancer, 
however, the sound should be introduced into the bladder, which will 



GENITAL TUMORS. 57 1 

aid in the dissection, and the neoplasm, if necessary, should be followed 
to the vesical neck. In one case I removed the urethra to its internal 
meatus without the patient suffering from incontinence. The incision 
should extend well around the disease, as far as possible within the bounds 
of healthy tissues. Bleeding vessels, rather frequent in this region, are 
secured with clamp forceps, and ligated if necessary with catgut ligature, 
or the sutures closing the wound are so introduced as to constrict the 
bleeding vessels. Care must be exercised that the bleeding vessel does 
not retract and continue to bleed. In one of my early operations for this 
condition this retraction of branches of the internal pudic caused hemor- 
rhage which followed the pelvic muscles backward, broke through and 
formed a large hematoma upon the posterior surface of the sacrum. In 
such a case, if the vessel cannot be secured otherwise, it will be better to 
tie the internal pudic on the external surface of the spine of the ischium. 
Fig. 471 illustrates the case of a woman who underwent operation in 
which both labia and clitoris were removed, and the tissue subsequently 
united, as seen in Fig. 472. Any inguinal glands involved should be 
extirpated, as well as the principal chain of lymphatic vessels leading to 
them. The circumjacent fat and cellular tissue should also be removed. 
When the disease has progressed too far to render radical operation 
successful, the putrid discharge may be temporarily controlled by the 
use of the curet and cautery. When the disease is too far advanced for 
this, the surfaces may be kept sprinkled with iodoform and pure charcoal, 
and dressed with gauze. The surface can be dusted with the following 
powder: 

I^. Salicylic acid, gr- iv ' 

Boric acid, o j 

Iodoform, 5ij 

Ext. eucalyptus, q. s. 

Kraske advises in extensive disease that the parts be thoroughly cu- 
reted, the lacerated parts cleansed, and the surface covered with flaps of 
healthy skin, as this procedure renders the course of the disease slower 
and the symptoms less painful. 

THE BLADDER. 

291. Tumors of the Bladder. Neoplasms occur in the female 
bladder in 9.8 per cent, as compared with their frequency in that of the 
male. The classification of Kiister, based on the histological structure, 
is the most generally accepted as follows : 

1. Epithelial group. Papilloma. 

Carcinoma. 

Adenoma. 

Cysts. 

2. Connective-tissue group. Sarcoma. 

Myxoma. 
Fibroma. 
Angioma. 

3. Muscle group. Myoma. 



572 GYNECOLOGY. 

292. The Papilloma is a pedunculated growth of branching con- 
nective-tissue stalk which contains the blood-vessels and occasionally 
muscle structure. Its surface is covered with one or more layers of 
epithelium, but without any infiltration of the bladder- wall at its base. 
It presents two types, the villous and the lobulated. The former may 
be very extensive, filling the bladder with great branching growths 
resembling a cluster of grapes. These growths originate in the mucosa 
and the submucosa. As they float in the distended bladder they resemble 
a great water plant. They absorb water and consequently are shrivelled 
up when kept in alcohol. They are most frequently found on the base 
of the bladder, though they may occur on the fundus. Their growth 
is slow and they are said to manifest a disposition to recur when removed, 
but this may be the result of growths which were overlooked when the 
original tumors where excised. They are distinguished from papillary 
carcinoma by the absence of any cell-nesting and alveoli in their structure 
and especially by the want of infiltration in the bladder-wall at the base 
of the growth. 

They are manifested by blood with the urine, although this may be 
an inconstant symptom and occur only at intervals. Urination may be 
frequent because the tumor so fills the bladder as to leave scant room 
for the accumulation of urine or the flow may be impeded or arrested by 
the branches of the growth floating into and obstructing the urethra. 
In some cases they may project from the urethra. 

293. Carcinoma. The commonest form of cancer of the bladder 
is the papillary and is consequently mistaken for the simple papilloma. 
This confusion is doubtless the foundation for the assertion that the 
benign growth often terminates in the malignant. Cancer occurs in the 
bladder mainly between the ages of fifty and sixty years, but has been 
seen as early as twenty-five years. The papillary growths present under 
the microscope the cell-nests and alveolar structure characteristic of cancer 
with more or less infiltration of the bladder- wall at the base of the growth. 
Consequently the tumor is more palpable than the ordinary papillary 
growth. In rarer instances, cancer appears as a hardening of the blad- 
der-wall with proliferation of epithelium, and later destructive ulceration. 
The infiltration of the bladder-wall, however, is unlikely to be general. 
While the disease may be found on the fundus or any other part of the 
viscus it occurs with greater frequency on the base. Its situation in this 
region leads early to pressure on the ureters developing obstruction to the 
flow and causing hydronephrosis. The changes in the urine from the 
accumulation of desquamated and decomposing tissue favors the early 
development of pyelitis and pyelonephritis. 

294. Adenoma is comparatively rare because of the infrequency of 
glandular tissue in the female bladder. However, it may occur and 
fill the entire bladder. 

Cysts of the bladder are not common. 

295. Sarcoma. Of the connective-tissue group, sarcoma occurs 
with the greatest frequency. It may become manifest at any age, 
though in contrast with cancer it is more apt to be early. 



GENITAL TUMORS. 573 

296. Myoma. The tumors are hard, whitish on the cut surface and 
arise from the vesicular muscular structure. They may remain sessile 
or become pedunculated. The more thinned the pedicle the less the 
vitality of the tumor until it is partially destroyed. 

Symptoms arising from neoplasms of the bladder will depend on their 
character. Small myomata and the papillary growths when small cause 
no symptoms. The most characteristic symptom of the presence of a 
growth will be hemorrhage which may seem to come on without any warn- 
ing. Often it will occur at night and the patient will insist that the blood 
comes from the vagina. After a bleeding the urine may become clear 
and there will be no return for days or weeks. After the tumor exists 
for some time the bleeding may be more continuous or recur with greater 
frequency. Malignant growths and the large papillary growths are 
particularly prone to bleed. In cases of hemorrhage care must be exer- 
cised in the use of the catheter as such tumors are often situated on the 
base of the bladder and may be injured by its insertion; or fragments of 
the papillary variety may float into the eye of the instrument and be 
pulled off as it is withdrawn, thus aggravating the hemorrhage. Masses, 
removed in this manner should be examined carefully. Papillary tumors 
situated on the trigonum are apt to float into the urethra and obstruct 
the flow of urine. When the growths have existed for a long period the 
urine becomes progressively bloody, coffee-like, or brownish. The tumor 
surface is black, red, often opaque, or a bright red. The urination is 
frequent, occasionally painful and associated with tenesmus as a result 
of the accompanying cystitis. Sometimes the patient will suffer from 
retention of urine as a result of the situation of the tumor which permits 
it to act as a valve closing the internal urethral orifice. The growth as 
a result of pressure or extension in malignant conditions may obstruct 
the passage of urine from one or both ureters. Pain and a sense of ful- 
ness is then experienced in the region of the kidneys and the obstruction 
is marked; uremic symptoms may follow. The protracted hemorrhage 
and the loss of rest and continued discomfort produce a marked anemia — 
even cachexia. Notwithstanding the distress the condition may continue 
for a period of years. In cancer, the urine smells like carrion and is 
mixed with blood-cells, pus, and debris of the disintegrating tissues, the 
evacuation of which, aggravates the tenesmus and the distress. The 
patient has an elevated temperature, rapid pulse, an anxious expression 
and the appearance of suffering from some grave condition. Cystitis 
develops early and the patient has but litt e comfort day or night. The 
invasion of the bladder walls, renders them rigid and so fixed that the 
capacity for accumulation becomes greatly limited. Extension to the 
peritoneum increases the distress and involvement of the ureters leads 
to their dilatation — frequently to hydronephrosis. 

Carcinoma of the bladder is oftener the result of secondary invasion 
from the uterus, vagina, rectum, or ovary. 

When it is invaded from the uterus or vagina, the bladder walls often 
break down and a fistula results, making the condition of the patient al- 



574 GYNECOLOGY. 

most unbearable to herself and those who are obliged to attend her be- 
cause of the stench of the urine and decomposing structures. 

Diagnosis. Examination is practised by palpation with two fingers 
of one hand in the vagina, while the fingers of the other are placed over 
the abdomen. The patient lies upon a table or hard couch. If the blad- 
der is emptied with a catheter, the greatest care must be taken and the 
possibility of hemorrhage produced by injury, remembered. The ex- 
amination is made slowly, carefully, and systematically. Generally, 
the abdominal walls are easily depressed. When the patient is unable to 
relax them, an anesthetic should be given. By careful investigation a 
tumor as small as a hazel-nut can be recognized, but pedunculated growths 
easily may be displaced to one side and elude the grasp, leaving one in 
doubt as to their presence. The ovaries are not unusually so situated that 
they may be felt, and lead to the belief that a vesical tumor is present. 
Diagnosis should not be based alone upon palpation. The urine should 
be examined chemically and microscopically. Cylinder-like cells are 
characteristic of papilloma. The older writers placed great stress upon 
the character of the hemorrhage — whether fluid blood, worm-like clots 
from the ureters, blood only, in the first or last portion of urine, or pure 
blood following catheterization. These distinctions afforded differential 
diagnosis between renal and vesical hemorrhage, but are now considered 
of little value as compared with cystoscopy. By direct investigation 
with the electric cystoscope the relation of the tumor to the vesical wall, 
its size, structure and character can be determined. The investigation can 
be made with the bladder filled with air or water. In bleeding, the 
latter is not so satisfactory unless the precaution has been taken to ir- 
rigate the bladder, preferably with hot water. When the kidney is the 
seat of the hemorrhage bloody urine can be seen flowing from the orifice 
of the ureter. The bladder can also be investigated by touch with a 
finger introduced through the urethra, but this should be practised with 
the greatest prudence, and, preferably, with the little finger only, because 
overdilatation may result in incontinence. 

Treatment. The only treatment for vesical tumors is operative. 
Following the diagnosis, the operative procedure should be employed 
as soon as the condition of the patient will permit. High fever, suppura- 
tion, cystitis, and marked anemia are considered as contra-indications. 

The removal of the growth is surprisingly easy. New loss of blood 
is endangered by every day's delay. Suppuration is not a contra-indica- 
tion. In large tumors irrigation does not secure disinfection, and sup- 
puration ceases only after the complete removal of the mass when the 
danger of nephritis is lessened. 

Access to the tumors may be secured through the urethra by the 
urethral speculum. Masses are seized with forceps and torn off, cut 
through by the galvanocaustic loop, cut away with scissors or forceps, 
or scraped off with a sharp curet. The last, however, should be used 
only when the finger can be introduced as a guide. The urethral opera- 
tion cannot be thorough. In malignant conditions, even should the desired 
structures be removed, there is danger of recurrence from reimplantation. 



GENITAL TUMORS. 575 

In large, broad-based, friable tumors, much injury may be done by 
scraping or tearing. The bladder soon fills with blood which is hard to 
remove and decomposes when the necrotic masses often cause cystitis 
and suppuration. Syringing the bladder with ice-water and astringents 
is painful. 

If the pain, loss of blood, and cystitis are aggravated by operation, 
it is hard to convince the patient that anything has been done for her 
relief. In extensive involvement or growths with a broad base the pre- 
liminary incision of the bladder is more effective and satisfactory, as by 
it the diseased structure and the field of operation are exposed to view 
and to more effective manipulation. 

Vaginal Incision. As a guide a catheter is introduced into the bladder, 
upon which a longitudinal incision is made through the middle line of the 
vagina, about five centimeters long, of sufficient length to permit the 
introduction of two fingers. The incision can be enlarged with scissors 
or with a knife above and below, affording considerable exposure of the 
bladder and its morbid growths. 

Bleeding vessels are secured by pressure forceps. The growths are 
then removed with forceps, scissors, knife, fingers, the galvanic loop, 
or the Paquelin cautery. In copious hemorrhage syringe with either 
ice-water or quite hot water; cotton sponges wet with the latter may be 
pressed upon the bleeding surface. Sutures cannot be used well because 
they cut through. Precaution must be exercised to avoid injuring the 
ureters. Hemorrhage is very severe in these operations and greatly 
obscures the view. The fistula should be closed, a catheter introduced, 
and the vagina tamponed to compress the bladder and decrease the 
bleeding. An ice-bag should be applied over the lower abdomen. 

The trifling mobility of the bladder in the region of the trigone renders 
it difl&cult to expose a bleeding vessel through vaginal incision, and the 
bleeding renders the field but little more accessible to view than through 
the dilated urethra, while through the latter the organ can be tamponed 
even more effectively than by the vaginal incision. It has been advised 
that operation for removal of tumors of the bladder should be preceded a 
month or six weeks by double nephrotomy for the establishment of drain- 
age. Such a procedure is especially valuable when it is intended to re- 
move the bladder, as the opportunities for the patient are much better 
than in the insertion of the ureters into the intestine and her comfort 
greater than if the ureters are inserted into the vagina. 

Abdominal Incision. A transverse incision gives more room than 
a vertical, though the two may be combined in a T-shaped cut. The 
difficulty in securing firm union and thus avoiding subsequent ventral 
hernia, however precludes its frequent practice. The vertical incision 
requires strong traction to be made on each side. Fritsch prefers the 
transverse incision, claiming that recovery is excellent if the incision is 
not over six or seven centimeters. The scar so disappears under the 
hair of the mons veneris that it is seen no more subsequently, even if the 
wound heals by secondary intention. It has the additional advantage 
that large vessels are not likely to be cut. He has seen a number of cases 



57^ GYNECOLOGY. 

in which extensive hernia had formed above the symphysis, but these 
were cases in which the object of the operation had been castration, 
suprapubic transverse section having been employed in the operation 
for castration, or cases in which the Trendelenburg posture had been 
employed for operations upon bladder fistula. In all these cases the scar 
tissue could still be seen. In twelve of these cases the incision had been 
twelve or more centimeters long. Such an extensive incision is unneces- 
sary in bladder operations. If the incision is made shorter, the recti 
unite with a firm scar to the pubic bone. 

Fritsch operated as follows : After the mons veneris and vagina have 
been thoroughly cleansed, and the bladder also irrigated with several liters 
of boric acid solution, the patient is put in the Trendelenburg position 
with the pelvis elevated. It is better to employ a large quantity of water 
than a trifling quantity of disinfectant solution. If the urine is clear or 
the discharge of blood quite fresh, syringing is unwise, as it can easily 
cause a hemorrhage. An assistant places his hands upon the abdomen 
in such a way as to keep the movable skin fixed, while a transverse inci- 
sion is made above the symphysis. The point at which the incision is to 
be made should be fixed before the skin is put upon the stretch other- 
wise upon drawing it up it may be found that the incision is too low. It 
should be made directly over the upper border of the symphysis. While 
one is operating in the loose fatty tissue behind the symphysis, an assistant 
pushes up the bladder with a thick male cathe er. The projection made 
by the end of the catheter is readily seen, the tissue above it is picked up 
with a tenaculum, and the bladder-wall is cut transversely above the end 
of the catheter. As soon as the bladder is opened the margin on either 
side is seized with a pair of pressure forceps and the bladder is prudently 
drawn down so that the forceps will not tear. The catheter is removed 
and the incision extended right and left by scissors until a broad wound 
is made in the vertex of the bladder, which will permit one conveniently 
to enter it with two fingers and inspect its inner wall. In this, as in all 
operations, it is important to proceed rapidly. The margin of the bladder 
is seized by ten or twelve pressure forceps, which hold the bladder open 
automatically and make its cavity visible. To sew the bladder to the 
margin of the wound would take more time. If the tumors are large and 
deeply situated, they may be discovered to the right or left by two fingers. 
The pedicle is seized between the fingers and the tumor prudently drawn 
up. As the structure tears easily, the bleeding point may sink back and 
vanish from view; when the bleeding is copious, one may be in doubt just 
what shall be done. It can be controlled promptly only through tampon- 
ade, which takes time; consequently, it is important, if possible, not to tear 
the tumor. 

Having fixed the situation of the tumor one must make the pedicle 
accessible. Often this may require an enlargement of the incision into 
bladder and abdominal wall. An assistant presses the region of the pedicle 
upward from the vagina. Hemorrhage may be controlled by a Paquelin 
thermocautery. The smallest points should be used in order to avoid 
extensive burning of the bladder epithelium. The ideal agent is the 



GENITAL TUMORS. 577 

galvanocautery. In small polypi and very small tumors the galvano- 
caustic loop does not act so well. To tie them off is, of course, difficult 
as the thread easily cuts through. Frequently the base cannot be encir- 
cled, on account of the proximity of the ureters. A deep ligature in the 
firm tissue may injure or occlude the ureter. A hot iron is not effective 
in arresting the bleeding, and yet this must be controlled in order to 
proceed. More favorable action is accomplished by long and continued 
djrect compression of the wound from the vagina and bladder. A strong 
vaginal tampon has a good influence. Ice-water may be used with 
advantage, and influences the closed bladder stili better. In the open 
bladder the nfluence is not direct on the bleeding vessels, as the bladder 
muscle, like that of the uterus or the placental part, contracts on the 
bleeding surfaces. WTien the pedicle is quite visible, so that one with 
the Paquelin can touch the proper place, we should employ the scissors 
to cut the growth away. The smooth, well-marked, cut surface can 
be compressed by the finger of the assistant, in the vagina, with a certain 
advantage. It may be necessary to tamponade both vagina and bladder 
and to apply a firm abdominal bandage. 

When the surface is exposed, hemorrhage is most effectively controlled 
by infiltration of the structures with i : 5000 adrenalin chlorid. I have 
seen large vessels contracted so effectively as to prevent what threatened 
to be a severe hemorrhage. 

The means by which hemorrhage is to be controlled must be deter- 
mined upon rapidly, whether it be the Paquelin, the application of a solution 
of iron, syringing with ice-water, compression with needle clamp forceps, 
or infiltration with adrenalin solution. The tampon should be prepared 
in advance. Large broad-based villous growths should be subjected to 
the sharp curet and scissors. Hemorrhage is often quite considerable. 
If the tumor is situated in the trigonum, so that there is no danger of 
injury of a ureter, the base of the bladder-wall can be penetrated 
and ligated. The possible discharge of urine through stitch-holes is of 
no significance, for in Shucking's operation for uterine fixation it is 
probable that the needle has frequently entered the peritoneal cavity, 
and it is only in rare cases that peritonitis appears. The necessity of 
preventing hemorrhage by a tampon after the operation excludes the 
possibility of complete suturing of the wound. We can, of course, draw 
together the bladder wound somewhat, as well as diminish that n the skin 
by lateral sutures, but in the middle it must be kept open for the eventual 
renewal of the tampon. In such cases it should be the rule to sew the 
bladder to the skin wound, in order to make its ca^dty accessible and to 
secure the tissue behind the bladder from overlying urine and wound secre- 
tion. As the patient recovers, the bladder suture cuts through, the organ 
sinks back, and the wound opening is gradually closed by granulations. 
When the opening continues too long, it should be narrowed by suture 
after artificial freshening of the wound. A permanent catheter should be 
introduced. This is necessary in all bladder injuries. With an incision 
into the bladder vertex, or in bladder resection, do not close the bladder 
wound completely, but place a strip of iodoform gauze in the opening left 
37 



578 GYNECOLOGY. 

in the wound. It has repeatedly occurred that the patient accidentally or 
purposely has had the catheter removed, when the urine can flow from 
the wound without injury; but if the wound is entirely closed, the re- 
moval of the catheter would work injury to the processes of recovery. 
After the bladder tampon is removed hemorrhage rarely occurs. Bloody 
urine disappears in from twenty-four to thirty-six hours after the removal 
of the tampon. While the catheter remains the bladder should be irri- 
gated with astringents or a weak solution of liquor aluminii acetici. This 
direct on applies also to the external wound, and the pledget should be 
wet with the same solution. The upper wound has a great tendency to 
close. If the granulations are weak, as in anemic patients, they can be 
stimulated by dilute alcohol, camphor, silver salts, or tincture of iodin. 
The appetite, which is lost through an excessive flow of blood from the 
tumor, improves, and the patient gains rapidly in weight. The patient 
should be permitted to rise from bed as soon as the wound is healed. 
When the operation is very late in the progress of the disease, the wound 
remains unaltered, the patient does not recover from the anemia and does 
not regain her appetite. Whether the patient dies from loss of blood, 
from loss of strength or from the influence of the operation is difficult to 
determine. 

The frequency of infection in the space of Retzius has led the majority 
of surgeons to the transperitoneal course for the removal of vesical tumors. 
An incision is made in the median line through all the structures of the 
abdominal wall, the bladder is raised, its peritoneal covering incised and 
stripped back, or the incision is carried through the bladder-wall. The 
intestines have been walled off previously and are held back by gauze 
packing. A sheet of rubber dam may be introduced about the bladder 
to prevent soiling the peritoneal cavity by its contents, and as it is opened, 
the urine can be absorbed and removed with gauze sponges. The blad- 
der can be spread out and its entire cavity inspected. Growths can be 
seized and held with fenestrated forceps and excised with thermo-cautery. 
Ordinarily it is wise to excise the entire bladder- wall with the growth. 
When the tumor is situated near the ureters, one or both may be injured. 
This will necessitate reimplantation. Where a large portion of the blad- 
der has to be removed for any reason, or the severed ureters are too short 
to admit of their reimplantation into the bladder, they should be brought 
out on the loins through the triangle of Petit. When the tumor occupies 
the fundus of the bladder it should be excised and the wound closed with 
the Connell's suture, which can be covered with a second row in the perito- 
neum. The abdominal wall is closed as in the ordinary operative proced- 
ure and the bladder drained by a permanent catheter until the vesical 
wound has united. 

In the event of the bladder being so extensively involved that its ex- 
tirpation is desirable, lumbar nephrostomy with ligation of the ureters, 
as suggested by F. S. Watson, should precede the extirpation by a month 
or six weeks. Permanent renal fistulse are thus established and the urine 
does not complicate the subsequent operation. Nephrostomy also affords 
opportunity to prolong life and lessen the discomfort in ineradicable 



GENITAL TUMORS. 579 

cancer of the uterus and vagina when the ureters are being compressed 
by the extension of the disease. The procedure can be utiHzed also to 
obviate the distressing odor in vesico-vaginal fistula from malignant 
ulceration. 

The extirpation of the bladder in woman is a comparatively easy 
procedure. After the peritoneal cavity has been opened by a median 
incision, the vesico-uterine reflexion of the peritoneum is incised and 
pushed off the fundus of the bladder. The latter is then separated by 
blunt dissection until it is only held by the structures about the urethra, 
when they are clamped on either side and the organ cut away. The 
clamped tissues are ligated with chromic catgut. As the course of the 
urine had been diverted by the previous nephrostomies and ligation of 
the ureters, the latter are cut when exposed without further consideration. 
When the uterus is involved either primarily or secondarily, and its ex- 
tirpation is proper, its removal makes that of the bladder more readily- 
accomplished as increased accessibility is afforded. Unless the peritoneal 
covering of the bladder has been sacrificed partially or completely be- 
cause of its involvement, it is utilized to close off the peritoneal cavity 
and the raw surfaces beneath can be drained into the vagina by gauze 
packing. 

THE VAGINA. 

297. Cysts of the vagina are very rare, and are generally formed 
in the remains of congenital structures. (Fig. 473.) Tumors originat- 
ing in the structure of the vagina are infrequent. Cysts are found as 
isolated tumors in the mucous and submucous membrane, in the former 
usually directly beneath the squamous epithelium. Rarely more than 
two or three occur in any individual case; Schroder, however, removed 
six from one patient. They are more frequently found upon the anterior 
wall, and are exceedingly rare upon the posterior. They vary in size 
from that of a pea to a hen's egg. The contents of these cysts are serous, 
more or less viscid or gummy, and are sometimes found mixed with blood. 
The epithelial lining of the sac may be either cylindric or laminated. The 
epithelium of some is ciliated (Abel). The origin of these growths is 
exceedingly difficult to determine. They have been attributed to the re- 
mains of Miiller's, Wolff's, and Gartner's ducts, to vaginal glands, or, 
according to Klebs, to dilated lymphatics. Neugebauer attributes most 
of them to remains of Gartner's canal. Hematoma of the vagina may 
serve as the origin for a cyst. Glands of the urethra may form retention 
cysts, and, as they develop, may project into the vagina. 

The symptoms will depend upon the size of the cysts. Ordinarily, 
they produce no inconvenience nor discomfort. Recently a patient 
underwent examination for a pelvic disorder, when a cyst the size of a 
walnut was found upon the posterior wall. 

Diagnosis. Vaginal cysts may sometimes be mistaken for cystocele 
or urethrocele. The use of the catheter during examination will demon- 
strate the thickness of the septum and the presence and size of the cyst> 



58o 



GYNECOLOGY. 



In the upper part of the vagina cysts are confounded with small tumors 
in Douglas' culdesac, such as prolapsed ovaries, a noncystic inflammatory 
condition of the tubes, and other inflammatory collections. A second 
vag na, which is closed and filled with retained secretion, may simulate 
a cyst. 

Treatment. Only the large cysts require any treatment The cyst 
may be opened and the sac cauterized most effectually with the actual 
cautery; or it may be packed with iodoform gauze, which affords drain- 




FiG. 473. — Cysts of the Vagina. 

age and sets up sufficient inflammation to obliterate it; or the entire sac 
may be enucleated. 

298. Fibroid tumors and polypi originating in the vagina are very 
rare. They develop in the submucous or deeper layers of the mucosa 
and push into the vagina. As they increase in size they become polypoid, 
and hang by a pedicle. The structure is similar to that of uterine fibroids, 
and the growth is slow. The most common situation is the superior 
portion of the anterior wall. They are often adherent to the urethra, 
and distend the vulva. They are usually small, although they have been 
reported as weighing two and one-half pounds. Bandier and Gremlier 



GENITAL TUMORS. 



581 



report one weighing ten pounds. I am indebted to the late Dr. John C. 
DaCosta for the illustration (Fig. 474) of a specimen which he removed 
from the vagina. As these growths increase in size, they become softened 
and ulcerate. They are more apt to develop during the period of sexual- 
activity, although Tratz reported one in a child of fifteen months which 
attained the size of a man's fist, and Martin one 3/4 of an inch long in a 
child two days old. 

Symptoms of the growth are largely dependent upon its size. If small, 
the tumor may remain unrecognized. Larger growths cause dysuria and 



I 




Fig. 474. — Myoma of the Anterior Vaginal Wall. {Dr. John C. DaCosta.) 



retention of urine. They project from the vulva, and the traction 
produces bleeding, ulceration, and erosion. 

Diagnosis. The growths are readily determined by their situation, 
slow growth, and mechanical disturbance. The softening, ulceration, 
and hemorrhage may sometimes lead to a diagnosis of malignant disease. 

Treatment consists in the removal of the growth by enucleation in 
sessile tumors, and by section of the pedicle in polypus. Hemorrhage 
is controlled by ligature or suture. 

299. Papillomata. Papillary or warty growths are found in the 
vagina, generally in association with similar growths about the vulva. 
Usually they appear as small isolated projections over the walls, but 
occasionally the entire vagina will be filled. 



582 



GYNECOLOGY. 



300. Malignant neoplasms of primary origin are very rare in the 
vagina. They most frequently extend from the uterus, rectum, vulva, 
urethra, or bladder, in one of three forms: i, papillary; 2, infiltrated or 
nodular both of which are included histologically under epithelioma; 3, 
sarcoma, either diffuse or circumscribed. The commonest form is the 
papillary although we may have carcinomatous infiltration, either circum- 
scribed, forming a broad-based excrescence, or a substitution of scirrhous 
for the normal tissue. 

Etiology. Malignant disease is most frequent during middle age. 
It is rare in youth, although I have seen one case of cancer of the vagina 





*¥* Mg- 












i*' ^A 


f' 




P^ 


^ 






-'^m" 


( 


.1 




*-^ v^^^wBB 


m 


/ 


J^ 


gg. 


J 




i 


L 


/ 



Fig. 475. — Primary Cancer of the Vagina. 

in a woman of twenty. Hegar once saw it when it was attributed to the 
irritation induced by a pessary. Epithelioma of the papillary form usu- 
ally affects the posterior wall, as a broad-based excrescence which rapidly 
invades the culdesac and extends downward toward the vulva. Epithe- 
lioma of the nodular or infiltrated form appears as nodules which become 
confluent, sometimes localized about the wall of the urethra The 
ulceration advances rapidly, and may burrow into neighboring organs, 
producing rectovaginal or vesicovaginal fistula. The disease extends 



GENITAL TUMORS. 583 

by the lymphatics the pehdc to cellular tissue. When it is situated in 
the anterior wall, the lymphatic glands of the groin are also involved. 

Symptoms. Very early, vaginal epithelioma causes hemorrhage, which 
will be aggravated by locomotion, coition, or the various procedures in 
examination. There is a profuse purulent discharge which is exceedingly 
offensive. Pain is not so marked as in disease of the uterus, unless in 
the later stages. The principal symptoms are the mechanical obstruc- 
tion to coition and to delivery from stenosis, and the watery, bloody, and 
offensive purulent discharge. In a case recently under observation the 
disease had involved the anterior wall of the vagina, having apparently 
originated in the urethra. It formed a large scirrhus-like mass extending 
upward over one-half the anterior vaginal wall. The patient suffered 
from great inconvenience in urination, having frequent attacks of re- 
tent'on and severe pain. 

Sarcoma occurs in two varieties: i, the diff'use sarcoma of the mucous 
membrane, often seen in young children; 2, fibrosarcomatous growths, 
or melanotic sarcoma. Epithelioma, or cancer, may be distinguished 
from sarcoma by the use of the microscope. In the former we note the 
characteristic assemblage of the epithelial cells, forming the pearly bodies, 
and preservation of the walls of the blood-vessels; while in the latter, 
the cells are more or less unconfined by connective-tissue stroma and the 
blood-vessels appear as mere sluiceways or blood-channels. 

Trea ment. The thin wall of the vagina is but slightly resistant to 
the progress of malignant disorder, and the disease is rapidly transmitted 
by the lymphatic vessels to the deeper cellular tissue of the pelvis, so that 
by the time the patient affected with cancer or sarcoma comes under 
observation, little can be done in the way of treatment beyond relieving 
her from the discomfort produced by the accompany ng symptoms. 
Complete recovery is rare. Von Eiselsberg, in a case ot cancer which 
involved the whole of the rectovaginal septum, resected the coccyx and 
established an artificial anus in the sacral region after extirpating the 
whole of the diseased part. The patient rapidly recovered and had con- 
trol of her stools. In a patient of mine, when the disease had proceeded 
from the rectum, involved the posterior wall of the vagina and the peri- 
neum, and extended close to the cervix, I removed the coccyx, resected 
the sacrum, excised six inches of the rectum, removed the uterus, ovaries, 
tubes, entire posterior wall of the vagina, and the posterior commissure of 
the perineum. The rectum was stitched to the sacrum posteriorly, and 
to the anterior wall of the vagina anteriorly, the peritoneum having been 
closed previously. (Fig. 542.) A colostomy had been performed upon 
the patient before she came under my observation. After the patient 
had recovered from the pelvic operation the opening- in the intestine 
was dissected out and the two ends of the bowel were reunited. The 
patient was under observation for nearly thirteen months. The contrac- 
tion of the intestine at the site of the former colostomy was sufficient 
to give the patient warning of the passage over it of feces, so that she could 
prepare herself for the evacuation of her bowels and avoid soiKng her 
clothing. 



584 GYNECOLOGY. 

THE UTERUS. 

301. Myofibromata are benign growths of the connective-tissue order 
which occur in the cervix as well as in the body of the uterus. They 
consist of connective tissue or of muscular structure combined with 
connective tissue. Where the connective tissue predominates, they are 
designated by the term fibromata, and where the muscular structure, 
as myomata or fibromyomata. The pure myomata consist of little more 
than muscular structure and exist only in the early stages. They usually 
appear s ngly and may attain to a rather large size. 

The myomata are the most frequent form of uterine growths. Care- 
ful examination will disclose such a growth in 20 per cent, of all the women 
who have reached the age of thirty-five years (Bayle), in 40 per cent, 
of women of fifty years (Klob), but in the great majority the tumors 
are small. The growth of a tumor is slow; when rapid increase in volume 
is observed, it arises, not from an increase of tumor elements, but from 
a disturbed condition of tissue fluid, which will be considered later. 
The most favorable condition for rapid growth is an intimate vessel 
union with the uterus. 

It is the generally accepted view that fibroid growths increase in 
size only during the period of sexual activity, and remain stationary or 
undergo atrophy after the climacteric. It is quite probable that no 
myoma ever originates in the uterus prior to puberty nor subsequent to 
the menopause. A tumor has been reported as having been found in the 
uterus of a girl aged ten years, but no opportunity was afforded to demon- 
strate the correctness of the diagnosis by microscopic investigation. 

Sutton reported a childless widow, who had never menstruated, 
but who had carried such a tumor for ten years. Peter Muller and 
Joseph Taber Johnson both assert that sometimes the growth continues 
to increase after the cessation of menstruation. Hofmeier says that 
such increase occurs in those myomata which stand in nutritive union 
with the peritoneum through organized bands of adhesion. The truth 
of this is especially indicated in omental adhesions, which greatly influ- 
ence the progress of the growth. He cites a woman in whom a thirty-five 
pound myoma, with numerous interstitial and omental adhesions, had 
continued to grow for a year after the menopause. 

A solitary myoma is rarely found in the uterus. The disease gener- 
ally exists as a multiple tumor formation. Over fifty growths have been 
found in one uterus. J. Bland-Sutton reports a uterus which contained 
one hundred and twenty myomatous growths, varying in size from a pea 
to an egg. They vary from a tumor the size of a pea to an enormous 
growth. After death Hunter removed a tumor that weighed 145 pounds 
from a woman whose body subsequently weighed but ninety-five pounds. 

How much the growth of myomata is influenced by the activity of the 
sexual organs remains difficult to determine, but the fact that myomata 
originate and have their greatest growth during the years most favorable 
for procreation cannot be without significance. Myomata occur with 
about equal frequency in the married and unmarried. Observation does 



GENITAL TUMORS. 585 

not justify the assertion that the size to which they attain or the rapidity of 
then: growth is influenced by the married or the single state. Some regard 
sterility as a cause of myomata, others as a consequence. 
Winckel and Schroder state the following conclusions: 

1. Fibroid growths originate without relation to marriage or to preg- 
nancy. 

2. Sexual excitement favors growth. 

3. The presence of a growth inclines to prevent child-bearing. 

4. Pregnancy promotes growth. 

Pathologic Anatomy. Whatever the origin, fibroid growths are found 
in either the body or the cervix of the uterus, in larger proportion in the 
former situation, and more frequently in its posterior wall. 

The consistence of the growth varies with its structure. A soft mus- 
cular mass presents, upon section, a reddish-pink color. Wavy, glisten- 
ing bands run in every direction, but have a tendency to form whorls 
about individual centers, owing to the origin of the disorder along the 
course of blood-vessels. The cut surface of a fresh section presents 
an uneven appearance, because the elasticity of the fibrous tissue causes 
the softer muscle surfaces to bulge. The mass is enveloped by a false 
capsule, produced by compression changes in the uterine structure. The 
capsule varies in thickness according to the site of its development. If 
the growth has originated in the middle layer, the capsule is thick and 
well formed; but if immediately beneath the peritoneum or the mucous 
membrane, the capsule will be very thin or even may be absent. 

About the tumor is a layer of loose connective tissue which permits 
ready enucleation. Occasionally there are numerous fibrous bands 
to the capsule, which render enucleation difficult, and are so frequent 
as to appear like a hyperplasia. 

The tumor is surrounded by numerous large vessels, from which it 
is nourished, but they do not penetrate its substance to any great depth. 

The vascularity of the structure is slight as compared to that of the 
uterine wall, for well-formed vessels are rareV found away from the cir- 
cumference. In the softer variety the blood-vessels are comparatively 
numerous; in the harder varieties they are scant. 

Microscopic Appearance. The comparative amount of muscular 
and connective tissues varies widely. In young and rapidly growing 
tumors the muscular tissue predominates and the capsule or line of de- 
marcation between growth and uterus is ill defined. As the tumor 
becomes older and more mature, there is a substitution of connective 
for muscular tissue, and the growth becomes hard and dense. (Fig. 476.) 
The section differs in appearance according to its direction. A longi- 
tudinal section presents cells of an elongated shape with rod-like nuclei, 
while a transverse section resembles groups of round cells. Occasionally 
between the muscle bundles are spores — lymph-glands lined with endothe^ 
Hum. They develop from cellular proliferation about the capillaries, 
and, with increase of connective tissue, may grow to large size. (Fig, 

477-) 

Varieties. Bishop follows Gusserow's classification and divides my- 



586 GYNECOLOGY. 

omata into the multiple and encapsulated and the single and nonencapsu- 
lated. The former are found most largely in the body of the uterus, 
while the latter grow from the cervix. This division is based upon struc- 
ture. The multiple growths are hard and firm. They consist largely of 
fibrous tissue, apparently mature, and no longer continue to grow. They 
are also called fibromata. The single growth is soft and elastic. 
Largely supplied with vessels, it is rapid in growth. In its structures the 
muscular tissue will be found to predominate. Single structures are 
known as liomyomata or fibromyomata. All myomata originate within 



: . I 



I' 



yV , .... n f > J /h 



i , .-." ■!{) S^^ 



A 7, 'M 



/ 



> 



; 



>/ 



'^ \ . . I 



/'% 






'I J ^ 






c 



■-^ ■ - ' .•■■' ■ T '^ 



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I'r \ ■ M 



Fig. 476. — Microscopic Section; Myoma Uteri. {Coplin.) 

the uterine wall, but upon their proximity to its inner or outer surface 
will depend their future progress. The most frequent classification, 
and the most useful in practice, is a division of myomatous growths ac- 
cording to their situation into: i. Submucous, intramural, or concentric 
(capsulated, nonencapsulated) ; 2, interstitial, mural, or centric; 
3, subperitoneal, extramural, or excentric (capsulated and nonencapsu- 
lated) ; and 4, fibromyomata of the cervix. 

Degenerative changes which may occur in the life-history of such a 
growth are indicated by the terms edematous, colloid or myxomatous, 
fibrocystic, calcific, necrobiotic, necrotic; but these changes are not 
sufficiently constant to justify their employment to indicate a distinct 
classification. 



GENITAL TUMORS. 



587 



The same statement can be applied also to the further division which 
is sometimes given: sarcomatous, adenomyomatous, telangiectatic, 
lymphangiectatic. 

302. Submucous fibroids, according to the proximity of their 
origin to the mucous surface, present two varieties — the encapsulated 
and the nonencapsulated or free. The former develop in the wall and 
are extruded beneath the mucous membrane by the uterine contractions. 
The second variety, the free, originate immediately beneath the internal 
surface, and are not supplied with a capsule, but are closely enveloped 
by the mucosa. An encapsulated tumor may become free through 
absorption or thinning of its capsule from pressure. 

The encapsulated variety is much larger than the free. Nature re- 
gards such growths as foreign bodies and endeavors to extrude them from 




Fig. 477. — Liomyoma of the Uterus. B. and L., 1/6 in. obj.; i in. oc. 



the uterine walls. Under this action a submucous fibroid may become 
pedunculated, when it is known as a submucous or fibroid polypus. 
(Fig. 478.) The muscular capsule may resist expulsion and prevent 
pedunculation, while the tumor bulges into the uterine cavity from a 
more or less broad base, and is called a sessile submucous fibroid. (Fig. 

479-) 

The sessile and pedunculated submucous tumors enlarge the organ 
and increase its vascularity. (Fig. 480.) The repeated contractions, 
together with the expulsive efforts, lead to hypertrophy of the muscle- 
wall to such a degree as to simulate pregnancy. The circulation in the 
entire mucous membrane, and especially in that portion covering the 
tumor, becomes obstructed, leading to severe hemorrhages. 

The severe pressure frequently causes atrophy and ulceration in the 
free variety, and the production of grave secondary changes, such as 



S88 



GYNECOLOGY. 



sloughing and gangrene. Compression of the neck of a polypus may 
cause edema, and when acute, can produce gangrene or sloughing of 
the mass, and a fatal termination. In the slower form the chronic edema 
often may be mistaken for a cyst. Uterine contraction may lead to elon- 
gation of the pedicle of a pedunculated fibroid and cause its extrusion 
from the external os into the vagina, where it can be recognized readi'.y 
and removed. (Fig. 481.) The elongation of the pedicle may become 
sufficient to permit the mass to hang from the vulva. The expulsion into 
the vagina may be sudden, but generally it occurs slowly. Very^rapid 




Fig. 478. — Submucous Myoma (Polypoid). 

expulsion of a tumor with a short pedicle may produce partial or com- 
plete inversion. Not infrequently the polypus may be felt projecting 
from the os during menstruation, while it disappears during the intervals; 
this condition is known as intermittent polypus. 

In rare instances the tumor may be completely and spontaneously 
separated and extruded by the efforts of the uterus. 

The pressure of the uterine or vaginal wall upon the tumor some- 
times causes ulceration, from which adhesions may form and by which 
the nutrition is maintained.. A polypus may be so firmly gripped bv 



GENITAL TUMORS. 



589 




Fig. 479. — Sessile Submucous IMyoma. 




Fig. 4S0. — Submucous Myoma OccupWng Uterine Cavity. 



590 



GYNECOLOGY. 



the cervix as to cut off its supply of nutrition and cause it to slough. 
The gangrene may spread upward and produce a fatal result. Such a 
condition can easily be mistaken for cancer. 1 

4 




Fig. 481. — Submucous Myoma Extruded into the Vagina. 




Fig. 482. — ^Voluminous Myomata Occupying Anterior and Posterior Walls. 

P 303. Interstitial, mural, or centric fibroid growths develop in the 
parenchyma of the uterus, frequently attain to enormous size, and involve 



GENITAL TUMORS. 



591 




Fig. 483. — Local Interstitial Myomata. 




7iG. 4S4. — Circumscribed Interstitial Myomata. 



SO-f 



<;yni';('(h,()«;v. 



Ilic cnlirc sIiik liiir ol llic iilcni;;, vvlicii llicy ;ii(- llicii known .1;. Ilic (liiTiisr 
or \\h' i^if^Jiiiln lil>M»nl (I'l;; |-v'.) A ;,(((»n(l \;iii('ly is Ilic ( in iim 
snilM'd |.^cii('inl loini (I'i^^. •i^'j); Ilic lliiid, Ilic ((xjil iiil('r.slili;i,l lil»i(>i<l. 
(I''ig, .1^/).) In Ilic I'ciicial circiimsc rihcd v.iiicly, ns (N'sciIIkjI hy 
S(:hHi(l(M', Ilic wnll <»l Ilic iihU'llH ITiny l»c lillcd l.y ;i |;ii;'c iiiiiiihcr ol 
^•[niwllis. III Ilic l()(iili/,c(l lihroinn u siii/^dc or Iwo or llirc<' inlcrslilijil 
lilnoiiwilii iiuiy I)c Iniiiid. These ).;r()wllii^ lire sihuiled in llie w.'ill of Ilic 
ori^nn, Hiiiroiindcd hy miischvlihers nnd Ilic loo.c M>iiiic(live lissiic (.ip 
sul(% from wlii( li Ilicy rcndily cjin he ciiik lc;ih(l. In Ilic dilTiise Idrm Ilic 
elllirit HliU( line <»l llic iilcrilH seerirs lo Ik- l;ikcii ii|) hy ||ie ^rrowlli, ;ind 
il i: dilln nil In li\ :i !;liiii|> iHudci ol liinil.il imi Ixlvvccn llic /'^rowlli ;iiid 




KlU. 4H5. Hhnr. ( >|M'ii('i|, ;;iinwiiif> Mulniilr Inlriiniial Myoiii.tlii 

liic nhiiiK Willi. 'riic;ic |',inwlli;i, when llic\ nll.iin n. liir^v. sizo, frc- 
i|iieiillv diiivv oiil Ihe lower porlion ol the uleriis as n. |>e(liel(% which 
may Ix- allcniialed lo Ihe lhi( kness (d" Ihe lin^^er and Iwisled, us seen in 
oiH- case \>y Kii'.lci, where, in Ihe lwi:;l, llic loi;;i(Hi was Iwo Jind one 
hail limes. The ((-i\i(al canal had hccii oMilcialcd. ( )eeusiona.lly, 
ihe nierine hody is lonnd scjiaralcd lioni llu »ci\i\. The niuseulur 
;liin hue ol Ihc nlciiis ilsell nnderp;oes hy|>eiiro|>hy in Ihese ciises, par 
licnlaily when Ixil lew f^rowlhs occupy Ihe wall. The jilerine wall 
IxMoincs llii( keiicd, ils ca.vih' i!> iiwreascd, and Ihe (avily undergoes 
vaiioici ( haiif^cs in ils shiipe and si/.e, a( ( ordiii)-', lo Ihe dc\'ciopmenl (d 
Ihe lumor and ils proi<'<'lion inio il. (lMf(. .|Ss ) The inlluenn' <d llu; 
growlh upon ihc ciidoiiicli inm is iiiosi inaikcd. In ;i lai>^e intei'sliliul 
m\'oni.i il iiia\' hctonic .lioni'.h dis.hiidcd, iiol ml rcipicnlly thin and 



GKNITAL TUMORS. 



593 




Fig. 486. — Sectioned Surface of Uterus, Showing Several Fib 

b, large subserous fibroid 



rumors: a, Uterine Cavitv 




38 



Fig. 487. — Serous Surface of Same Specimen: a. Cervix. 



594 GYNECOLOGY. 

atrophied. (Figs. 486 and 487.) In other cases there is a hypertrophy 
of the entire mucous membrane, occasionally only of the glands; in others, 
the interstitial tissue between them is increased. (Fig. 488.) Occasion- 
ally, the condition is complicated by malignant edema. In the great 
majority of cases hypertrophy of the mucous membrane is found associ- 
ated with these growths. (Fig. 489.) Indeed, the endometrium may 
be three or four times its normal thickness. 

304. Subperitoneal growths (also called subserous, eccentric, or 
extramural) are generally spheric or ovoid masses springing from the 




Fig. 488. — Uterus Incised, Containing Interstitial Fibromyomata: a. a, Tumors; &, uterine 

cavity. 

external surface by a more or less distinctly marked pedicle. Like the 
submucous, these growths are sessile or pedunculated. While the latter 
class are polypi, that term is more generally applied to intra-uterine 
growths. 

The surface of the growth may be smooth or irregular, according to 
the contraction of the connective tissue. A division into free and encap- 
sulated is made: the former covered by the serous layer, which is closely 
attached, without capsule, to the surface of the tumor; the , latter 
or encapsulated, are covered with a layer of muscle-wall beneath the 
peritoneum. 

The free are hard and only attain a small size; the encapsulated are 
soft and often become enormous. The pedicle of the tumor varies in 
length and thickness. It may be short, thick, and permit but little move- 
ment between the tumor and the uterus, or long and attenuated, affording 



GENITAL TUMORS. 



595 



such marked freedom as to cause doubt whether the growth is connected 
with the uterus. The pedicle can sometimes become so twisted as to 
cut off the circulation of the tumor and lead to its loss of vitality, the 
development of gangrene, and subsequently to septicemia or peritonitis; 
or the tumor, in more fortunate cases, may become adherent to the 
surrounding viscera and lose its association with the uterus. Such a 
growth is nourished by its adhesions. Not infrequently a very movable 
tumor causes asci'e^, and thus sim.ula^es a malignant growth. 




Fig. 489. — Uterus Incised, Showing General Circumscribed Fibromyomata: a, Uterine cavity. 



305. Fibromyoma of (he C3ivlx. Cervical myomata, like those 
of the uterine body, are submucous, interstitial, and subserous. These 
growths originate in the body of the organ, and, by the process of enuclea- 
tion through contraction, may have been driven downward, either through 
the cervical canal or into its structure by splitting it externally or, as in the 
single noncapsulated tumor, had its origin in the cervix and grow^n either 
upward or downward. Single tumors may be either pedunculated or 
sessile, and rarely attain a size larger than a goose-egg, although they 
may completely fill the pelvis. (Fig. 491.) They cause contraction and 
prolapse of the uterus, and simulate inversion of the organ. They may 
be divided into two classes : 



596 



GYNECOLOGY. 



I. Those of the external os, in which the tumor is formed by a cyHndric 
or elongated Hp in the interstitial variety. (Fig. 492.) The submucous 




Fig. 490. — Subserous MyomatE 




Fig. 491. — Pedunculated Myoma of the Cervix. 

growths of the cervical canal are occasionally polypoid, which like slender 
stalactites, descend through the cervix by the splitting process. 

2. Tumors from the subvaginal portion. These are more important 



GENITAL TUMORS. 



597 



when developed from the external surface and situated between the 
layers of the pelvic floor. They become intraligamentary and exceedingly 
dangerous by pressure upon the ureter or upon the pelvic vessels; 
also when posteriorly they press upon the rectum and push the uterus 
forward and upward. Occasionally, the tumor crowds anteriorly 
against the bladder, between it and the uterus. Generally these tumors 
are found surrounded by a loose capsule, which permits of ready enucle- 
ation. Sometimes, however, there is no line of demarcation between the 
tumor and the uterine structure. 

Etiology. These growths occur more frequently than any other to 
which women are subject. Not infrequently they may attain to consider- 




FiG. 492. — Sessile Myoma of the Cervix. 

able size without the patient being aware of their existence, and are 
then recognized only by accident. The causes of their development 
are unknown. Recklinghausen attributed their origin to embryonic 
tissue, the remains of the Wolffian bodies. The irritation which charac- 
terizes fibromata is not a physiologic irritation, like that of pregnancy, but 
a diseased impetus. It is an unusual kind of local irritation, associated 
with a weak or debilitated condition of the concerned spot. This in- 
troduces Cohnheim's view of tumor origin, that the local irritation was 
brought to development by the presence of tumor germs. The influence 
of sexual irritation is appreciated, in that statistics demonstrate that in 
the majority of cases the first indications appear during the second half 
of the third decade — between the twentieth and thirtieth years. The 
tumor forms in the first half of the fourth decade, shortly after the thirtieth 
year. These growths rarely develop before or after these periods^ 



598 GYNECOLOGY. 

although Biegel is reported to have seen one in a girl ten years of age, 
and Leopold the beginning of a myoma in a child. There has been much 
discussion as to the influence of the married or single state upon the 
development of these growths. The investigations of Moller show 
that ^'2.8 per cent, occur in virgins, 67.2 per cent, in those who are not, 
but one-half of the latter are sterile. Hofmeier says that the number 
of births does not stand in any relation to the causal formation of the 
growth, while Winckel believes the married are more predisposed, and 
the myomatous formation decreases the number of births. Shoemacher, 
on the contrary, asserted that the unmarried are more frequently affected. 
Hofmeier accounts for the relatively large number of unmarried women 
who suffer from myomata by the explanation that the tumor formation 
is one of the few causes which lead them to consult the gynecologist. 
Prochownik gives syphilitic infection as a cause, but the growths occur 
so frequently in individuals in whom there has been no possibility of 
such infection as to render this view of little value. Olshausen and 
Gusserow assigned local irritation as the etiologic factor. Shoemacher 
also looks upon menstrual congestion as a cause, but to give these reasons 
for the development of the disease is equivalent to giving none, as it is 
necessary to seek further for the cause of the irritation. Moller, already 
referred to, frequently found that a myoma the size of a pin's head was 
separated from the uterine muscle by a distinct layer of connective tissue. 
Small arteries could be traced into the growths, which still retained their 
three coats; consequently he doubted the theory that myomata arise from 
the muscular coat of the blood-vessels. The cause is sometimes con- 
sidered as congenital. The influence of heredity, as to whether there 
is a predisposition to the development of such growths in families, may 
be questioned. Heredity seems to be manifested in the greater apparent 
and comparative susceptibility of the colored race to the development 
of fibroid growths. It is not unusual to find several members of one family 
suffering from myomata. Among the various causes it is probable that 
sexual irritation should have the first place, and this irritation may have 
been engendered without the uterus having undergone the changes in- 
cident to pregnancy and labor. The abnormal irritation may be the 
result of masturbation, of psychic disturbances, of such unnatural proc- 
esses as the evasion of maternity, of the psychic phenomena engendered by 
body-contact with man, of sexual agitation, and of other factors which may 
produce repeated injurious influence. It is quite possible that defective 
development or an abnormal position of the uterus may exert a marked 
influence in the development of these growths. Mann reports a childless 
widow at the age of forty-three, twice married, who had never men- 
struated. For ten years she had a large fibromyoma. It still remains 
evident, however, that in any individual myoma we cannot positively 
assign a cause which can be considered a definite reason for its develop- 
ment. 

Symptoms which should cause a suspicion of the existence of myomata 
are hemorrhage, pain, and abdominal cramp, especially when associated 
with progressive enlargement of the abdomen. The symptoms of the 



genital' TUMORS. 599 

individual case will depend on the variety of tumor present. In the sub- 
peritoneal or in the interstitial, which have not encroached upon the uterine 
mucosa, the growth may attain considerable size without manifestation 
of any symptoms which would attract the attention of the patient. Fre- 
quently, especially in the unmarried, such growths become so large as to 
be remarked by others before the patient is aware of the condition. The 
growth will be suspected where there is a history of slow but progressive 
enlargement of the lower half of the abdomen. Occasionally the first 
symptom will be the inability of the patient to evacuate her urine properly. 
There even may be complete retention requiring the aid of a physician. 
Then' the tumor may be recognized for the first time. The tumor may 
be situated in the pelvis, fill it completely, and push the uterus above it. 
If the growth simply presses against the bladder, interference with 
evacuation may be slight, or, more likely, cause frequent micturition 
because of the inability of the bladder to distend. Urination may be so 
frequent and so painful as to lead patient and physician to suppose that 
cystitis exists. The growth may press upon the rectum, causing consti- 
pation, retention of gas, tympanites, interference with the circulation of 
the lower rectum, hemorrhoids, prolapse, marked anal pruritus, burning 
of the anus, the existence of a fissure, and often the veins of the anus as 
well as those of the vulva become varicose. Incarceration of a growth in 
the pelvis, may, by severe pressure on the surrounding structures cause 
sloughing and gangrene of the pelvic soft parts. (Fig. 492.) An intra- 
ligamentary tumor may push the uterus to the opposite side, and may be so 
large compared with it, that it will be difficult to determine the situation 
of the uterus. (Fig. 493.) Pressure of a tumor on the pelvic nerves 
may produce pain down the posterior surface of the leg in the form 
of sciatica, a crural neuralgia over the front of the leg, or marked pain in 
the sacrum. While such symptoms may occur in any form of myoma, 
they are more characteristic of the subperitoneal and interstitial varieties, 
especially when the latter has not encroached upon the uterine cavity. 
In the interstitial variety growing toward the mucous membrane and 
causing obstruction in its circulation and engorgement and degeneration of 
the overlying mucosa hemorrhage is a marked symptom. In the sub- 
mucous varieties bleeding is a more or less constant and characteristic 
symptom. Hemorrhage may be manifested by an increase of the men- 
strual flow (menorrhagia) or an irregular bleeding (metrorrhagia) may 
result. Hemorrhage, as before stated, is a very prominent symptom of 
all submucous growths. The bleeding varies, and is not affected by 
the size of the growth, since a small polypus will cause just as severe, if 
not a greater hemorrhage than results from a large tumor. 

In submucous growths the menses become profuse and prolonged, 
resulting in marked anemia and great debility. The bleeding may be 
continuous and very free for a few days, then there is a period of brown 
secretion, to be followed again by profuse bleeding. Blood may be dis- 
charged as a bright fluid blood or in large clots. Clotting has no signifi- 
cance, and depends upon the size of the uterine cavity in which the 
accumulation occurs, or it may take place in the vagina. Pedunculated 



600 GYNECOLOGY. 

polypi may be associated with severe flooding. Intermenstrual hemor- 
rhage may alternate with periods of amenorrhea, which may continue for 
months, and when the patient is congratulating herself that she has re- 
covered, another severe hemorrhage occurs. The bleeding occurs from 
two sources: i. From the mucosa covering the tumor; 2. from the gen- 
eral uterine surface. The first is active as the tumor encroaches on the 
mucosa only after it becomes peduncu ated. The bleeding comes from 
and is due to irritation of the circumjacent uterine mucosa and the pro- 
duction of an interst tial endometritis. In some of the smaller growths 
the tumor will be found quite anemic. Metrorrhagia from rupture of 
veins in the superimposed mucosa is frequently associated with a profuse 
watery discharge, which adds to the depression and prevents the patient 
from regaining her health. 

Leukorrhea, or discharge other than blood, is increased during the 
progress of these growths. The extrusion of the growth into the uterine 
cavity increases the normal watery discharge from the uterine glands. 
Interference with the circulation and consequent hypertrophy of the 
glandular tissue cause a profuse secretion. This may be truly gland- 
ular in character and mixed with the desquamated epithelium. Pus- 
cells and blood-cells also may be found, according to the degenerative 
processes, which sooner or later ensue. As the cervix becomes dilated, 
its glands add their thick, viscid secretion to the abundant discharge. 
The partial or complete extrusion of the growth influences its circulation, 
frequently causing necrosis of portions of its surface or even the entire 
structure, according to the extent of the constriction. The discharge 
is often bloody, purulent, or watery, contains necrotic masses of detritus, 
and produces an extremely offensive odor. The patient, and not infre- 
quently her attendant, has cause to suspect the existence of malignant 
disease. 

In all varieties of tumor the blood supply of the growth itself is very 
slight, as no large vessels enter the tumor directly. Where the neoplasm 
is of some size, this deficient blood supply must affect the nutrition of its 
structure, and causes the production of toxins which have a deleterious 
influence upon the health of the individual. This is evident from the 
appearance of such patients where hemorrhage and leukorrheal discharge 
are not a factor. It is probable that these toxins have an influence upon 
the heart muscle and other structures of the body, causing conditions which 
are so frequently found associated with the presence of a fibroid growth. 
It is probable that in these toxins will be found the explanation for the 
mental disturbance that is so frequently associated with the develop- 
ment of such growths and which usually clears up with their removal. It 
may also explain the occurrence of ascites which frequently is associated 
with subperitoneal growths. 

Pain is not a constant symptom. It is frequently more a sensation of 
weight or pressure in the pelvis and upon the surrounding organs. Intense 
pain may characterize very small growths, but is conditioned somewhat 
upon their situation. A growth pedunculated or so situated upon the 
uterine wall that it projects into the internal os may act as a ball-valve, 



GENITAL TUMORS. 6oi 

and be the cause of the most agonizing labor-like pains. I have seen this 
form of dysmenorrhea in many cases. (Fig. 493.) In one patient it 
was so severe as to require the administration of two grains of morphin at 
each menstrual period to render it endurable. An operation subsequently 
revealed that the patient had a double vagina and a bicornate uterus with 
two distinct cervical canals in a common cervix. In one of these cavities 
was found a submucous tumor which, by a nipple-like projection, filled 
up the internal os, and explained the violence of the dysmenorrhea from 
which this patient had suffered. 

Sterility is a common symptom and conception is the exception. The 
inflammatory changes consequent upon the presence of the growth render 
the reception and retention of the fecundated o\aim unpropitious. More 
frequently than is generally appreciated, the tubes have undergone second- 
ary changes which result in the occlusion of their abdominal extremities, 
and they are found to form retention cysts. Furthermore, pathologic 




Fig. 493. — Bicornate Uterus. Both Cornua Containing Myomata. 

conditions of the ovaries are sometimes found, and this fact, also, is not 
given the consideration it merits. Constipation, hemorrhoids, anal fissure, 
prolapse, and pain arising from pressure upon the rectum are more or less 
constant symptoms and signs. Vesical tenesmus, cysts, frequent mic- 
turition, retention of urine, dilated ureter, and hydronephrosis are produced 
by disturbance and obstruction of the urinary organs. Not infrequently 
the first symptom which leads to the discovery of the growth is the re- 
tention of urine, from pressure upon the vesical neck. The myomata may 
also be the cause of retention of urine pressure upon the ureters interfering 
with the entrance of the secretion into the bladder. As a consequence, 
renal dilatation occurs even to the extent of sacculation of the kidneys. 
In one of my early operations for myoma, upon a patient who had carried 
a large tumor for some twenty years, death followed very shortly after the 
operation. The autopsy revealed that both kidneys were distended, 



02 GYNECOLOGY. 

forming thin-walled sacs, that the ureters were several times their normal 
size, and that their walls had become greatly thinned. The protracted 
hemorrhages, profuse discharge, severe labor-like pain, and pressure 
upon the neighboring viscera are prone to result in a profound anemia, 
which is characterized by a straw-colored appearance of the skin, often so 
marked as to simulate cachexia and indicate plainly the gravity of the 
patient's condition. 

Diagnosis of Myomata.' A uterine fibroid may be suspected when 
there is a slow but progressive enlargement of the lower part of the ab- 
domen. It may occur in either the single or married woman, and need 
not be associated with any special indication of ill health. The physician 
should not overlook the possibility of its existence whenever a patient com- 
plains of pelvic weight or pressure, frequent micturition, difficult urination, 
or sudden attacks of retention necess tating catheterization. Indeed, in all 
such cases, the pelvic viscera should be examined preliminary or subse- 
quent to the use of the catheter. Uterine growths should be suspected 
also when hemorrhoids, fissure of the anus, frequent bleeding from the 
bowel, pain, difficulty, and distress during defecation exist. A patient 
should never be subjected to operation or treatment for hemorrhoids until 
the condition of the uterus has been determined. A Sister of Charity 
requested operation for severe hemorrhoids when pelvic examination 
revealed a group of subperitoneal and interstitial fibroids completely 
filling up the pelvis. She had never suspected their existence. Profuse 
menstrual flow or irregular bloody discharge occurring in the unmarried 
woman or in women giving no history of interrupted pregnancy, mis- 
carriage, or abortion, should cause suspicion of a submucous fibroid, 
particularly where this hemorrhage is associated with pain, often labor- 
like in character, indicating the efforts of the uterus to expel a foreign 
body. Often the hemorrhage will produce marked anemia without ema- 
ciation, which distinguishes it from that associated with malignant disease. 
No characteristic symptoms of myomata occur, consequently the physician 
is forced to rely upon the physical signs for diagnosis and confirmation 
of his suspicions. 

An important factor in the recognition of fibroid growths is their 
consistence in contrast with the surrounding soft structure of the unin- 
volved portions of the uterus by which their determination and delimita- 
tion is permitted. Alterations in the shape of the uterus, in relation to the 
situation of the tumor are of interest. A large growth may fill out and 
give the organ a spherical shape. Further uterine contraction forces the 
tumor into the cervix which may be distended, making it palpable at the 
external os. An intra-uterine polypus can be determined by palpation 
through the cervical canal. If the os is sufficiently open, the pedun- 
culation can be inferred by its mobility, and definitely determined by 
reaching the pedicle with the finger. In small fibroid growths with a 
long pedicle the growth may be felt through the uterine walls moving under 
the pressure of the finger, even though the cervix is undilated. During 
profuse menorrhagia, an offending growth is frequently extruded or the 
cervical canal sufficiently dilated to permit its recognition by the examining 



GENITAL TUMORS. 



603 



finger. A growth may be extruded during the flow and drawn back in the 
interval, producing what is known as an intermittent polypus. A growth 
filling up the pelvis may make pressure upon the large vessels and so 
interfere with the return circulation of the lower extremities as to cause 
enlargement of the superficial veins to compensate for the obstructed ab- 
dominal vessels. Pressure upon the ureters causes their dilatation, hydro- 
nephrosis, dilatation of the pelvis of the kidney, not infrequently saccula- 
tion with destruction of its secreting tissue, the formation of renal calculi, 
and even the occurrence of suppurative changes. These are character- 
ized by more or less renal pain and discomfort which may possibly mask 
the pelvic lesion. Interference with the cardiac or renal functions causes 
profound anemia, the appearance of cachexia, not infrequently disturbance 
of the veins of the lower extremities, phlegmasia, blocking of important 
vessels by particles of coagulated tissue, and possibly the formation of 




Fig. 494. — Intraligamentary Myoma. 

pulmonary and cerebral emboli. The diagnosis is effected by bimanual 
examination, the introduction of one or two fingers into the vagina or the 
finger into the rectum, and the other hand over the abdomen. Thus the 
uterus is carefully palpated and any enlargement of its structure recognized. 
If such enlargement or hardening of the organ exists, its size, resistance, 
and relation are studied carefully. A fibroid growth has a definite shape, 
is smooth in outline, well defined and has a characteristic resistance. 
It is important in the study of such a growth to arrive at a diagnosis not 
only as to its existence, but also as to the form of growth present. It 
is decided then whether the growth is an intra-uterine or a submucous 
tumor. When the cervix is patulous, further palpation determines 
whether the growth is sessile or polypoid. If interstitial growths occupy 
the uterus, their situation or the anterior or posterior wall or the fundus 
is determined, or, if subperitoneal, from what portion they spring. The 
latter growths are divided into three types: i, the growth from the fundus 
or anterior wall grows upward, and in its progress becomes pedunculated; 
2, it is pushed out through the lateral wall of the uterus practically splitting 



6o4 GYNECOLOGY. 

and spreading out the folds of the broad ligament and displaces the uterus 
to the opposite side (Fig. 494); 3, it grows downward from the posterior 
wall beneath the peritoneum and is not even in contact with it. In a 
small tumor as yet nonpedunculated, it may be difficult to determine 
by conjoined manipulation from which wall it has originated. The 
intra-uterine use of the sound, or better, dilatation and the use of the 
finger in the uterus with one hand over the abdomen or a finger in the 
rectum will establish the diagnosis and the relation of the growths to the 
uterine wall can be determined accurately by their smooth regular outline. 
A fibromyoma of the cervix presents a mass in the vagina, often filling it. 
The mass is quite movable, and between it and the vaginal walls the finger 
can be passed easily. Its situation external to the cervix precludes the 
probability of its having undergone necrosis from pressure, but occasionally 
the pressure may cause inflammation in the vagina, leading to agglutina- 
tion between the tumor surface and the vaginal wall. The tumor attach- 
ment is recognized by bimanual palpation accompanied by traction upon 
the growth. 

306. Differential Diagnosis of Myomata. An accurate diagnosis 
of any condition is secured only by carefully reviewing the conditions with 
which it may be confused. The conditions with which myomata are 
likely to be confounded are: 

Normal pregnancy. 

Ectopic pregnancy. 

Desmoid tumor of abdominal walls. 

Inversion. 

Carcinoma. 

Sarcoma. 

Incomplete abortion. 

Subinvolution with endometritis. 

Uterine displacements. 

Ovarian displacements. 

Ovarian cysts. 

Pelvic infiltrations. 

Sactosalpinx. 

Floating kidney. 

Normal Pregnancy. Amenorrhea, subjective symptoms, regular 
growth of the uterus, absence of hardness in its walls, and a sensation of 
elasticity are generally sufficient to determine the diagnosis of pregnancy. 
A limited amenorrhea may occur in a submucous myoma, and a patient 
go for months without a hemorrhage. On the other hand, hemorrhage 
occasionally complicates the early months of pregnancy. I formerly 
attended a patient who always suspected pregnancy if the menstrual 
flow was especially free, and she continued to menstruate for two or three 
months following each conception. Myomata may be present as small, 
edematous, subperitoneal nodules, which are sometimes mistaken for the 
extremities of the fetus. Calcification of a fibroid has caused it to be 
mistaken for the fetal head. The existence of the tumor does not preclude 
the possibility of pregnancy as a complication. Pregnancy associated 



GENITAL TUMORS. 605 

with fibroids should be suspected when the growth takes on more rapid 
enlargement, when the rapidity of the growth is greater than that which 
usually characterizes the tumor, and when a portion of it gives the sensation 
of elasticity. The regular shape, size, and outline of the uterus under the 
bimanual, with the contractions of the pregnant organ, which are absent 
in the nonpregnant, contrasted with the more or less firm resistance, the 
irregular enlargement, and the smooth nodular outline of the tumors 
should establish the diagnosis. In diagnosis the following case very 
graphically illustrates, as shown in Figs. 504 and 505, that fibroid tumors 
under certain conditions may simulate pregnancy. The patient, about 
forty- two years of age, had applied to her physician for relief from an 
uncomfortable sensation associated with enlargement of the lower ab- 
domen. He pronounced her pregnant, confirmed the diagnosis and later 
it was coincided in by other physicians. I saw her some time after the 
normal period of the supposed pregnancy was completed when she was 
referred to me as a case of delayed labor. Examination disclosed the 
cervix to be of normal size. However, above, in front of it could be felt 
distinctly two rounded masses with a sulcus between which led the exam- 
iners to take the condition for a fontanelle. The abdomen was enlarged 
to the size of a pregnancy at six months. There was a sensation of 
elasticity or rather of distention in the abdomen. A movable mass could 
be felt which impinged against the abdominal wall when the hand was 
suddenly removed. This sensation was attributed to ballottement of 
the fetal body. Bimanual examination, however, convinced me that the 
mass was extra-uterine. I was confirmed in this by the history, as the 
woman never ceased to menstruate and the enlargement had increased 
only to a slight extent in the last few months. Investigation of the case 
caused me to pronounce it multinodular myomata, one of which had a 
rather thick pedicle, permitting it to be pushed away, but firm enough to 
bring it back against the abdominal wall and thus produced the sensation 
of ballottement. The freedom of movement was accounted for by the 
presence of free fluid in the peritoneal cavity. Operation confirmed this 
diagnosis. 

Extra-uterine pregnancy will present symptoms in the early stage similar 
to those of a normal pregnancy, as amenorrhea, nausea, mammary 
changes, etc., associated with a history of colic-like pains on either side of 
the pelvis, with later a marked tearing pain, possibly attended by fainting, 
and symptoms of internal hemorrhage. Subsequently a mass will be 
found in the side or an increase in the size of the abdomen will take place, 
but this enlargement will be less symmetrical than is the case in a normal 
pregnancy. The examination of the patient will ordinarily reveal the 
uterus slightly enlarged, somewhat softened, free from any irregular or 
nodular masses, possibly displaced to one side, or crowded forward by a 
mass which is situated in the side of the pelvis or in Douglas' pouch pos- 
terior to the uterus. In the advanced stages the parts of the fetus may be 
felt, probably with greater ease than if the fetus was contained within the 
uterus. 

Desmoid tumor of the abdominal walls presents the same hardness and 



6o6 



GYNECOLOGY. 




Fig. 495. — Large Desmoid Tumor of Abdominal Wall Weighing, upon Removal, Nineteen 

and One-half Pounds. 
a, Adipose tissue of abdominal wall; b,b, recti muscles from which tumor originated; c, aponeu- 
rotic sheath of recti muscles; d, portion of tumor projecting downward into pelvic cavity. 



GENITAL TUMORS. 



607 



resistance as does a fibroid growth of the uterus, but developing in the 
muscular structure of the abdomen it generally becomes by its weight more 
or less pendulous and usually does not attain to large size, so is readily 
distinguished from the deeper seated uterine growths. In my clinic in 
the spring of 1905 a colored woman of thirty years, who had given birth 
to two children, presented herself with a distention of the abdomen which 
was quite symmetrical and extended from the pelvis to beneath the ribs. 
Palpation disclosed a firm, hard mass, occupying the entire abdomen and 
quite movable. The diagnosis was made of interstitial uterine myoma 
and resort made to operation. Incision in the median line, however, ex- 
posed the tumor as continuous with the abdominal wall, and did not af- 
ford access to the peritoneal cavity until it had been carried some distance 




Fig. 496. — Histologic Section of Desmoid Tumor. 
a, Blood-vessel; b, area of specimen showing edema; c, long spindle-shaped cells; note scarcity 

of nuclei. 

above the umbilicus. The growth sprang from the right side of the ab- 
dominal wall, was covered upon its inner surface with peritoneum, and 
had no association with the uterus. (See Fig. 495.) The tumor weighed 
nineteen pounds. (Fig. 496.) Notwithstanding that this growth grew in- 
ward from the under surface of the muscular walls and filled the abdominal 
cavity, careful bimanual examination should have revealed that it had no 
connection with the uterus and that the abdominal walls could not be 
moved over it. 

Incomplete Abortion. The uterus may be larger than normal and the 
patient give a history of irregularity and more or less continuous bloody 
discharge from the uterus. Careful questioning will afford a history of 
amenorrhea and belief of the patient that she has been pregnant. The 
uterus will be large and softened. When the cervix is patulous, the finger 
can be introduced, revealing the enclosed embryonic tissue. 



6o8 GYNECOLOGY. 

Inversion of the uterus may be associated with a myoma with a short 
pedicle, attached neir to the vterine fundus. The efforts at extrusion of 
such a mass, after dilatation of the cervical canal, may cause a dragging 
upon the fundus and gradual inversion. A polypus with a moderately thick 
pedicle, when extruded from the os, may be distinguished from the body 
of an inverted uterus with difficulty. A myoma is said to be less sensitive 
than the uterus, but this is not sufficiently characteristic to be of much 
value in diagnosis. Upon inspection the inverted uterus shows the orifice 
of the tube upon either side. In each condition the neck of the uterus can 
be felt encircling the pedicle of the tumor like a cuff. The diagnosis is 
best established by introducing a finger into the rectum, while traction is 
made upon the tumor. The cup-shaped cavity of the inverted uterus 
will be felt, in case of inversion, where in ordinary cases the uterine fundus 
should be situated. The exercise of recto-abdominal touch, while traction 
is made upon the protruding mass, will afford an unfailing method of 
determining the diagnosis. A sound passed into the uterus in cervical 
tumor will be found to pass at one side the entire length of the ordinary 
uterus. In an inversion of the organ the sound will pass an equal distance 
on all sides of the tumor. However, the diagnosis ordinarily can be 
accomplished without the use of the sound. 

Carcinoma and Sarcoma. Profuse bleeding, pain, and d'scharge are 
common both to fibroid tumors and malignant diseases of the uterus. 
In the majority of cases the offensive discharge associated with malignant 
disease is not found in myomata. Recognition of this fact has sometimes 
led to error in judgment. Thus, in a case where a myomatous growth 
has pushed through the cervix, and for a length of time has been constricted 
by it, caries or superficial necrosis follows as a result of the interference 
with the circulation in the tumor, from which the careless observer may 
be led to a diagnosis of malignant disease. Digital examination of such 
a patient, however, reveals the fact that the vagina is occupied by a tumor 
which is firm in consistence, smooth and regular in outline, not friable nor 
easily broken down, thus differing materially from the friable necrotic 
mass which is found in the vagina in the cauliflower growth of malignant 
disease. A sloughing fibroid within the uterine cavity may occasion 
difficulty in the diagnosis. It causes a thin, watery discharge, which is 
exceedingly offensive. It may have caused repeated attacks of hemor- 
rhage. The associated loss of blood, with the absorption of the products 
of decomposition from necrotic tissue, produces a condition of sapremia 
which is with difficulty differentiated from malignant disease. In such 
cases, however, diagnosis is determined by dilatation of the uterine canal. 
The necrotic growth forms a large tumor, one which is more resistant, 
fragments of which broken away and examined present the regular 
lamellated structure of a fibroid growth, but nowhere is seen the nesting 
or collection of epithelial masses surrounded by a connective-tissue stroma 
pathognomonic of carcinoma nor the homogeneous mass of cellular tissue 
with an absence of true blood-vessels which characterizes the sarcoma. 

Subinvolution with endometritis is a chronic inflammation of the uterine 
parenchyma, and when it has existed for a length of time, the uterus be- 



GENITAL TUMORS. 609 

comes firm and hard, indistinguishable from the hardness of myomata. 
The enlargement of the uterus is uniform, involving the cervix as well, 
while in fibroid growths the enlargement is pronounced only in that part 
of the uterus which comprises the growth. 

Uterine Displacements. Flexions of the uterus are the varieties of 
uterine displacements most readily confounded with fibroid growths. 
Indeed, a fibroid growth may be the cause of the displacement. The 
growth, by its smooth outline and situation, may form such an angle as to 
cause one to regard it as the fundus uteri. These are the cases in which 
the sound can be employed successfully to ascertain whether the direction 
of the uterine canal corresponds to the position of the tumor. The cases 
are rather few, however, in which the gynecologist cannot locate the fundus 
uteri accurately and detect the relations of the growth thereto by prac- 
tising the bimanual examination in association with the vagino-abdominal 
or recto-abdominal touch. Such an examination will reveal the greater 
consistence of the growth, its rounded, smooth outline, and the extent of 
its association with the uterus. In a flexion, when the organ is straight- 
ened between the internal and external fingers, the normal outline of 
the uterus is found restored. 

Displacements of the Ovary. The ovary is likely to afford confusion 
of diagnosis only when it is firmly fixed to the uterus by inflammatory 
exudate or has become somewhat enlarged. Its situation, the inability 
to recognize the ovary in any other situation, and its extreme sensitiveness 
should reveal its true character. 

Ovarian Cyst. It is frequently difficult to differentiate between a 
fibroid tumor with a long pedicle, which has become edematous, and an 
ovarian cyst of the glandular or dermoid variety. If the cervix is grasped 
with a double tenaculum, while an assistant, with the hand over the ab- 
domen, draws up the tumor, rectal examination affords a more exact 
determination of the relation of the tumor pedicle to the uterus. Such an 
examination, under anesthesia, generally will be more satisfactory. The 
existence of a fibroid tumor does not preclude the possibility of pregnancy. 
Some years ago I narrowly escaped operating on a patient who gave a 
history of profuse bleeding three weeks previously. On the right side 
of the uterus was a firm, hard growth recognized as a fibroid. The left 
side of the abdomen elasticity or indistinct fluctuation was supposed to 
indicate an areolar glandular growth closely adherent to a uterine fibroid. 
\Vhen I came to cleanse the vagina a fetal foot and leg were projecting from 
a dilated os and I delivered a partly macerated fetus. After the placenta 
was removed, the uterus contracted and a fist-sized fibroid was disclosed 
on the right. The patient recovered, and the fibroid growth decreased in 
size during the process of involution, rendering its removal unnecessary. 

Pelvic infiltrations are recognized by the previous history of inflamma- 
tion and the irregular and undefined outline of pelvic exudate. 

Sactosalpinx usually is preceded by a history of inflammation. The 
mass is felt at one side of, or posterior to, the uterus. When adherent to 
the latter, the connection is so irregular and undefined as to reveal its 
character. 

39 



6io 



GYNECOLOGY. 



Floating kidney forms a tumor at a higher level than that at which 
fibroids usually are found. The fingers can separate it from the symphy- 
sis and promontory of the sacrum, and both can be palpated. This 
procedure would be impossible in a uterine growth. The floating kidney 
generally can be pushed back to its normal position. 

307. Alterations and Degenerations. During the active develop- 
ment of a myoma it becomes larger, swollen, and more edematous with 
each menstrual period. As the flow ceases, the growth decreases in size 




Fig, 497. — Myoma Uteri with Large Intraligamentary Fibromata. 
a, Anterior and posterior leaflets of broad ligament; h, tumor. 

and becomes more firm and resistant. In the submucous and interstitial 
varieties cessation of menstruation or the climacteric is delayed from five 
to ten years longer than would occur in a woman who was free from uterine 
disease. With the menopause, however, the growth usually diminishes 
in size and undergoes a process of atrophy. The tumor becomes firm and 
hard and its size remains fixed. Or, it may become soft, and, with this, 
a process of metabolism occurs in which it gradually disappears. Small 
growths have disappeared almost entirely after the climacteric. 



Such 



GENITAL TUMORS. 



6ll 



changes also occur occasionally during a pregnancy or in nonpuerperal 
cases without assignable cause. Frequently a patient has been greatly 
disturbed by the knowledge, obtained through examination, of a fibroid 
growth in her uterus. Months or years later another investigation 
reveals no indication of its existence. If the second examination be made 
by another physician, he may be inclined to believe that the condition has 
been misrepresented, and do great injustice in expressing such a suspicion. 
Edema of large fibroids, especially of the interstitial variety, is not 
infrequent. Edema is caused by constriction or torsion of the pedicle, 
through which the venous circulation is obstructed, while the arteries 
continue to pump in the blood. The obstructed circulation in such growths 




Fig. 498. — Fibrocystic Tumor of the Uterus. 

may result in edema as a first stage of a necrobiosis. The interstices 
of the tumor become filled with serous fluid, so that the enlarged growth 
affords a sensation of indistinct fluctuation or elasticity, so marked that 
only the recognition of the continuation of the growth with the cervix 
renders one able to differentiate it from an areolar glandular ovarian cyst. 
After the removal of such a growth an incision into its wall will permit the 
discharge of a large quantity of serous fluid. I once extirpated the uterus 
for such a growth, when an eminent surgeon examining it asserted that it 
was a fibrocystic tumor. An incision through the structure, however, 



6l2 



GYNECOLOGY. 



failed to reveal a single cyst, while nearly a gallon of fluid drained out of 
the growth in the two hours following its removal and incision. 

Fibrocystic tumors (Fig. 498) result from dilatation of the lymph-spaces 
in the tumor, from degeneration of a portion of its structure and the 
formation of a cavity, or possibly, in rare cases, from the separation of the 
structure of the tumor in edema. 

Calcification. As the tumor matures its direct circulation is reduced 
and nutrition reaches its structures largely by transudation. Under 
certain unknown chemical conditions of the blood this fluid is heavily 
charged with lime salts which are deposited within and upon the surface 
of the tumor, causing it to become enveloped in a stony shell or to form a 
calcareous mass. Lime salts were formerly administered to favor such 
formation and thus arrest further growth in myomatous tumors, but it 




Fig. 499. — Submucous Fibro myoma Undergoing Cystic Change. 

was soon recognized that other and more vital tissues of the body were 
equally vulnerable to such deposits. In the examination of growths which 
have undergone such change, the sensation given of pressure against bone 
renders such a tumor harder and more resistant than the ordinary mature 
fibroids. Not infrequently plates of bone will be felt to break beneath 
the palpating finger. Undoubtedly the cases reported of the expulsion 
of uterine calculi were myomata which had undergone this calcareous 
change. A submucous or interstitial fibroid so changed may subsequently 
be expelled by the uterine contractions. Amyloid degeneration has been 
reported in one patient. Fatty degeneration has been evident from the 
macroscopic appearance of tumors I have removed, although it has been 
asserted that fatty degeneration of such growths is never confirmed by the 
microscope. 

Colloid myxomatous degeneration, according to Virchow, is an effusion 
of mucous fluid between the muscular bands. The presence of a mucin, 



GENITAL TUMORS. 



613 



proliferation of the nuclei and small round cells permits of its being dis- 
tinguished from simple edema. 

Inflammation J Suppuration, and Gangrene. Inflammation of a growth 
may result from injury, traumatism, compression or obliteration of its 
nutritive vessels and from septic infection following an exploration. 
Septic inflammation may follow exploration or delivery. The rapid 
changes which take place subsequent to the delivery of a patient carrying 
a large fibroid may cause interference with its nutrition and result in 
inflammation and suppuration. Suppuration may occur external to the 




Fig. 500. — Myoma of the Body and Cancer of the Cervix. 

capsule, in the cellular tissue about it, or in the tumor structure. Sup- 
puration may have been preceded by mortification of a small part of an 
interstitial or submucous growth. The gangrenous portions may be 
eliminated spontaneously, or, retained, cause putrid infection. When a 
large growth is retained after having lost its vitility, it may disintegrate 
gradually, slough, and be expelled through the cervix into the vagina as a 
large sloughing mass, or cause such marked symptoms from putrid infection 
that the life of the patient will be lost, regardless of operative interference. 



6i4 



GYNECOLOGY. 



Such conditions are mistaken for malignant disease. Some years ago I saw 
a patient whose physician, after an examination, assured her family that 
she was suffering from an incurable malignant growth, which must termi- 
nate her life speedily. The history of profuse hemorrhage ; of an exceed- 
ingly offensive discharge; the appearance of profound anemia and a 
condition resembling cachexia, afforded apparent confirmation of the 
correctness of his suspicion. The finger disclosed a large mass filling the 
vagina, which, instead of being soft and friable, as a cauliflower growth 
would be, was roughened on its inferior, but smooth upon its upper, 
surface, was quite movable, and supported by a distinct pedicle, which 




Fig. 501. — Uterus Incised, Displaying Numerous Fibromyomatous Growths and Incipient 

Cancer of the Cervix. 
a, Shows invasion of cervix by cancer. 

projected from the cervical canal. The neck of the uterus was thin, 
pliable, and without infiltration, which demonstrated that the diagnosis 
of malignant disease was incorrect, and that the patient was suffering 
from a fibroid polypus whose surface was necrotic. In cases of doubt the 
history, more or less firmness of the growth, distinct arrangement of the 
structure, even when gangrenous, and absence of any cellular infiltrate are 
sufficient to afford a correct diagnosis. An abscess may develop either in 
the wall or within the growth itself. 

Malignant Degeneration (Fig. 500). Cancerous degeneration of a 
fibroid growth has not been demonstrated, nor is it easy to understand 
how it could occur, unless the growth contains glandular tissue and is. 



GENITAL TUMORS. 615 

consequently, a fibroid adenoma. A growth within the uterus renders it 
less resistant and promotes the probability of malignant degeneration of 
the endometrium. The most frequent malignant degeneration, however, 
is infiltration of the fibroid growth by sarcomatous processes. 

308. Mixed Growths. — Enchondroma, Sarcoma, Osteoma, and 
Carcinoma. The origin of these growths is uncertain. It is possible 
that they originate in one of two ways — either in transformation of the 
cells which produce other tissue species, or in an invasion in which the 
growth is penetrated by the neighboring proliferating masses. Thus, 
we have myochondroma, myosarcoma, and myocarcinoma. The first 
of these is very rare. The second is less rare, and grows rapidly from a 
small invasion. The normal filamentous structure of the fibroid growth 
is soon lost in a homogeneous mass, which rapidly becomes necrotic; 
the tumor then forms a mere thick shell. Vessels are often eroded with 
the necrosis of the mass and extensive hemorrhage may occur into the 
cavity. Malignant degeneration is not confined to the growth, but in- 
vades the surrounding healthy tissues. The enveloping cells are large, 
irregular, rich in chromatin, and contain several nuclei. Sanger asserts 
that all myomatous growths containing irritation cells are sarcomatous. 

Myocarcinoma arises from carcinomatous alteration of the surface of 
the polypus, or by development from the glandular constituents of an 
infiltrated adenomyoma. 

309. Complications. The progress of a fibroid growth from its 
origin in the wall of the uterus to its subsequent extrusion, and the changes 
and lesions to which it may be readily subjected, will afford reasonable 
explanation for the many complications which are associated with it and 
influence its progress. The most important, because one of the most fre- 
quent, of these complications is that of inflammation. 

1. Inflammatioji may involve the structure of the growth or only its 
superficial surface. It affects the growth as the result of decreased nutri- 
tion after its extrusion into the peritoneal cavity, when it becomes a foreign 
body. Nature in her efforts to protect the body tissue surrounds it with 
plastic material, from which the tumor may receive additional and 
necessary nutrition, fixing it in relation to the structures immediately 
about it. Such adhesions may involve the intestine, the mesentery, or 
the abdominal wall, and may lead, through traction upon the tumor, to 
still further thinning or attenuation of its pedicle, and, finally, to separa- 
tion from the body of the organ, so that occasionally such growths are 
parasites removed from their original attachment and nourished through 
inflammatory adhesions. The causes for inflammatory changes may be 
divided into — i, those incident to alterations in the tumor; 2, irritation 
changes in the peritoneum from the presence of the growth as a foreign 
body; 3, infection. Infection may have its origin in disease of the ap- 
pendix, the Fallopian tubes, or through direct transmission from the 
intestinal cavity. 

2. Ascites is a second, though less frequent, complication of myomata. 
(Fig. 504.) This is attributed to irritation of the peritoneum from ped- 
unculated subperitoneal growths. (Fig. 505.) It is more probable that it 



6i6 



GYNECOLOGY. 



is the result of a toxin from the lowered vitality of the growth. Ascites is 
more frequent in malignant than in benign growths, and its presence should 
always awaken the fear that grave changes are taking place in the growth. 
I 3. Disease of the Tubes (Fig. 502). Disease of the Fallopian tubes as 
a complication of the presence of fibroid tumors is very common. The 




Fig. 502. — Myoma Uteri Complicated by Pyosalpinx. 

disorder may be a simple hydrosalpinx or a pyosalpinx. Adhesions may 
be extensive, greatly complicating any operative procedure. The most 
frequent cause of adhesions is undoubtedly infection which has traveled 
through the uterus. The presence of fibroid growths favors congestion 
of the pelvis, and makes the tubal mucous membrane a favorable soil. 
Pressure upon a Fallopian tube may interfere with its circulation, cause a 




Fig. 503. — Uterus Containing Several Fibroid Tumors Complicated by a Large Tubo-ova- 
rian Cyst, a, a, Shows sites of fibromata; h, round ligament. 

distention of its cavity, and the formation of a tubal collection. This 
defective drainage produces regurgitation into the pelvic peritoneum from 
the abdominal end of the tube; a peritoneal inflammation; a closure of the 
tube and the formation of a hydrosalpinx or pyosalpinx, according to the 
exposure to or absence of infection. 



I 



GENITAL TUMORS. 



617 



4. Ovarian Hematoma. The distention of an ovary by the accumula- 
tion of blood is no unusual complication of myomata. The ovarian sac 
usually is adherent and filled with a thin, dark, bloody colored fluid. 
The sac wall is easily broken and is rarely removed without rupture. 

5. Pregnancy. The presence of fibroid growths is a cause of sterility, 
but does not necessarily preclude the occurrence of pregnancy. The early 
recognition of the complication is of the utmost importance, as the course 
of pregnancy may have a marked influence upon the rapidity of the growth, 




t 



Fig 504. — A :Myoma Which, from the Associated Ascites, Had Been Mistaken for 

Pregnancy. 

while the growth may favor the premature arrest of pregnancy. This 
complication is of such importance that it may be studied from various 
standpoints. 

a. The Influence of the Myoma upon Conception. It can be appreciated 
readily that a fibroid growth — for instance, of the polypoid or submucous 
variety — renders the uterine mucosa unprepared for the retention of the 
fecundated ovum. Frequently the removal of a polypus from a woman 
is followed very shortly by conception, even though years of sterility had 



6l8 GYNECOLOGY. 

preceded. The engorgement of the uterine mucosa, occasioned by the 
presence of a sessile submucous or of an interstitial growth, encroaching on 
the uterine canal, the profuse and irregular hemorrhages associated with it 
and the constant and excessive secretion from the glandular structure, pre- 
sent conditions exceedingly unfavorable for the fecundation of the ovum. 
b. Influence of Pregnancy upon the Myoma. The increased congestion 
of the uterus incident to pregnancy causes greater nutrition of the tumor, 
often results in its rapid increase in size, and the growth which was situated 
in the pelvis is raised out of it forming a more formidable mass. Occa- 
sionally the growth is slow, adhesions so fix the uterus that it cannot rise 
out of the pelvis, and there follows an impaction similar to that in a gravid 




Fig. 505. — Tumor Shown after Removal. 

retroflexed uterus. Sometimes the tumor rises quickly into the abdomen, 
or it may remain in the pelvis, and not emerge therefrom until the sixth or 
seventh month. Intraligamentary growths become altered by pressure 
and cause marked distress. A fibroid polypus is sometimes extruded into 
the vagina and removed without any indication of interference with the 
pregnancy. Marked changes in size, form, and consistence of the uterine 
growth are noticed. The increase in size is often due to edema. Venous 
engorgement frequently occurs as a result of obstruction of the veins, 
while the blood is continually poured into the structure by the less readily 
controlled arteries. (Fig. 505.) Where a number of fibroid growths are 
situated together in the pelvis, they frequently become nonpedunculated 
subserous growths, flattened from pressure. The circulation can be 
obstructed to such a degree as to result in necrosis. Such changes require 
early and prompt interference in order to save the life of the patient. 



J 



GENITAL TUMORS. 



619 



c. The Influence of the Myoma upon Pregnancy. — An intra-uterine 
growth, covered as it is by mucous membrane, aggravates the tendency 
to bleeding. Hemorrhage and changes in the uterine mucosa may be so 
marked as to cause premature interruption of pregnancy; or the ovum 
may be situated so low in the uterine cavity as to cause the attachment of 
the placenta over the cervix. This is known as placenta prcevia and the 
mother's life is endangered by it as the pregnancy advances. The situa- 
tion of the tumor may favor retroversion of the gravid uterus and its 
impaction in the pelvis, or the tumor itself may be impacted. The pres- 
sure of a fibroid growth upon the tubes may favor tubal pregnancy, which 
will be unsuspected until it ruptures into the abdominal cavity and the 
patient's life is imperilled. 




Fig. 506. — Myoma Complicated by Pregnancy. 



d. Influence uponLahor. Small fibroid growths, especially those which 
are not larger than a walnut or an orange have but slight influence, 
if any, upon the course of labor. Larger tumors, situated in the pelvis, 
may interfere with labor and require operation for their pre\dous removal. 
Occasionally, with the changed position of the patient and elevation of the 
hips, the tumor may be pressed out of the pelvis; or, one situated low in 
the uterus, under dilatation of the os and elevation of the cervix as the 
dilatation progresses, may be lifted out of the way. Interstitial and broad- 
based subserous growths cause irregular and ineffective uterine contrac- 
tions which prolong the labor. The existence of myomata has been found 
to complicate the results greatly. Experience has demonstrated that 
labor complicated with myomata in the cervix is provocative of a greater 
maternal mortality than is associated with contracted pelvis. The infant 
mortalitv is still more serious. 



620 



GYNECOLOGY. 



Large subserous growths, when above the pelvis, in or near the fundus 
of the uterus, exert no influence upon the progress of labor. Cervical 
growths, however, are very important, as from their situation they may 
occupy a position below the level of the pelvic brim, and necessarily 
interfere with the delivery of the fetus. Even when a growth is found in 
the pelvis thus, it is often raised spontaneously as the process of dilatation 
proceeds. Submucous growths may be extruded into the vagina previous 
to the inception of labor and then be removed. If the tumor becomes 




Fig. 507. — Uterus Containing Large Fibroid Tumor and Three Months' Fetus. 

edematous, it is more compressible and less of an obstacle to the progress 
of delivery. 

Course and Prognosis. Myomata, when small, produce few symptoms, 
if any, and those are vague. Some cause serious disturbance until the 
occurrence of the menopause, when the great majority of them undergo 
atrophy and diminish by induration during the process of involution. 
Atrophy is hastened occasionally by pregnancy, so that patients in whom 
a fibroid growth has been recognized lose the tumor entirely during 
pregnancy or when it terminates. When it outlasts the term, it disap- 
pears during the puerperium. Occasionally there is a marked eiTect on the 



GENITAL TUMORS. 021 

general health, associated with fibrous cysts of fibromyomata — particu- 
larly after the critical age. A tumor that remains quiescent is not neces- 
sarily small, but may reach to the level of the navel before the patient is 
aware of its existence, when examination is made for some intercurrent 
condition, or for the treatment of symptoms produced by the tumor, the 
cause of which the patient had ignored. In the majority of cases, the 
tumor does not threaten life directly nor indirectly. In this respect it 
differs from carcinoma or ovarian tumor. Carcinoma demands operation 
as soon as discovered, for life is destroyed by its progress; in myomata the 
need is less imperative for the growth may bear no relation to the disease 
for which relief is sought. In myomata of large size, extending above the 
umbilicus, the prognosis is good in young individuals, but the future 
health of the patient is endangered. In a woman still under thirty-five 
years of age with a tumor as large as a pregnancy at full term, one can 
assert with security that her life is threatened, and her capacity for 
suffering is limited. Operation is no longer elective, but necessary, 
as the danger from the operation is less serious than the unfavorable 
influence produced by the growth of the tumor. In such cases the phy- 
sician is justified in asserting that the operation is advisable, and cannot 
be postponed for ten or twenty years with the hope that the patient will 
still manifest good powers of resistance and a fair chance for recovery. 
WHien the tumor comes under observation near middle life in the fifth decade 
— about forty-three to forty-five years of age — advice must be governed by 
the symptoms. However, the degenerative processes and complications 
which may occur are more dangerous than the removal would be. A 
tumor w^hich swells during menstruation may undergo considerable dimi- 
nution during the climacteric, and when under observation may be per- 
mitted to continue unless symptoms develop. In all cases the prognosis 
depends upon the age of the patient. Great size of the tumor and 
complex symptoms affect the future course. All complications that 
increase the size of the tumor render the prognosis worse in a younger 
patient. In such cases the operator must be influenced in his action 
by the progress. Complications that may be regarded as hazardous 
in the young, are less serious in the older because the longer duration 
of the disease renders the organism more resistant. Prognosis is bad in 
cases of severe heart lesions, as fatty degeneration, though this is difficult 
to recognize in the living. Other complications may render the prognosis 
of the myomata bad, but not necessarily make the outlook for operation 
worse. The first indication of heart affection should be regarded as an 
indication for prompt operation. The prognosis is rendered much worse 
if the myoma has undergone a malignant degeneration, which, however, 
is rare. Rapid growth of the tumor is not necessarily an indication of 
malignant change, but rather of cystic degeneration, which renders the 
prognosis of the further continuation of the grow^th worse, approaching 
in this respect the ovarian condition. The prognosis of all small tumors, 
especially those which cause more or less hemorrhage, is not always 
unfavorable. The danger is never so great as it appears to the patient. 
The discomfort produced by the condition, anxiety about further duration, 



622 GYNECOLOGY. 

and increase of bleeding impel the patient to consult her physician. 
In such cases it is difficult to arrive at a correct judgment, as the patients 
do not appreciate the fact that life is not necessarily threatened when 
menorrhagia is profuse. In the consideration of methods of treatment 
the fact must be kept in mind that the productive activity is injured, 
even though a bad prognosis is not to be asserted. The danger lies in 
the long duration of hemorrhage, which thereby renders the general 
condition worse. The gravity of the prognosis is increased by marked 
general disturbance. The appearance of hemorrhage cannot always 
be regarded as unfavorable. It proves that the spontaneous discharge 
of the tumor is taking place, following which the prognosis is improved. 
While it is true that a fibroid growth usually undergoes an abatement 
of its symptoms with the advent of the menopause, it is not unusual for 
such a growth to delay the climacteric beyond the ordinary period of life 
at which it would occur. Occasionally, the natural evolution of a tumor, 
which results in its conversion into an extraperitoneal or intraperitoneal 
growth, may cause separation from the weight of the tumor alone or 
from thinning of its pedicle. By straining in defecation or in vomiting, 
a polypus may be expelled. Rupture of a pedicle may limit the subse- 
quent progress of the growth. It may be nourished by the adhesions it 
has formed, or it may lie free in the peritoneum and undergo mummi- 
fication. A more serious result of spontaneous extrusion is mortification 
or gangrene of a tumor which has been expelled into the uterine cavity. 
Perforation of the neighboring organs, such as the bladder, the rectum, 
the rectovaginal pouch, or the abdominal wall may occur as the tumor 
develops. Frequently the two former conditions end in death; the latter 
in possible recovery. Causes of death are profound anemia from repeated 
hemorrhage; successive attacks of chronic peritonitis; disease of the 
kidneys; uremia and heart failure; rupture of cyst; or inflammation and 
gangrene. Sudden death has been observed as a result of embolism. 
Exploratory puncture favors the production of thrombi in the large 
venous sinuses. Death from shock after intravenous rupture has been 
reported. Where there are small subperitoneal growths which have 
been extruded beneath the peritoneum, and by their relations show no 
evidence of taking on growth, it is preferable that the patient should be 
left unaware of their existence. The various complications to which these 
growths are subject; the alterations which they may undergo during 
their progress ; the influence upon the health of the individual from pressure 
upon important viscera; the danger from separation of growths and sub- 
sequent gangrene; the possibility of their continued nutrition and growth 
subsequent to the menopause; and the occasional malignant degeneration 
of the mass, associated with the diminished mortality by early operative 
procedure, particularly that of hysterectomy, render it advisable that 
the extirpation of the growth should be practised. In the young the 
possibility of the occurrence of pregnancy with its attendant dangers 
is an important factor, and one which may be an indication for treatment. 
When a woman suffers from a condition which insures a maternal and 
infantile mortality it becomes a serious question whether she should be 



GENITAL TUMORS. 623 

advised to marry, or, if married, should not be subjected to prompt opera- 
tive interference. 

310. Treatment. The mere recognition of a myoma must not be 
considered as a necessary indication for its removal, or even treatment. 
In this respect myomatous tumors differ from ovarian and malignant 
growths. The latter especially must be removed early, for its continued 
existence results in destructive invasion of the organism. The myoma 
must cause symptoms in order to indicate interference. The external 
relations of the patient must play a great role in the method of treatment 
— the capacity of resistance, the ability to undergo rest during menstrua- 
tion, and to avoid severe bodily labor. Consequently in women of the 
working class, who cannot rest, the treatment is different from that 
which must be practised in those who are able to take care of themselves. 
There are some cases in which hygienic and dietetic rules must govern. 
Neither the growth of the tumor nor the severity of the hemorrhage will 
necessarily be influenced by the methods of treatment; but by the avoidance 
of severe bodily effort and the promotion of nutrition disturbance of 
the health equilibrium is avoided. 

The patient should be cautioned as to her manner of dress, and ad- 
vised to wear loose clothing, since it is exceedingly detrimental to crowd 
a myomatous uterus into the pelvis by wearing a tight corset. Tight 
clothing over an abdomen containing such growths may readily produce 
inflammation which will lead to extensive and unfortunate adhesions. 
When the abdominal wall has become greatly weakened by previous 
distention or the weight of a large tumor following the climacteric, the 
comfort of the patient may be greatly enhanced by wearing a binder or 
support which will prevent the tumor from falling forward. In such 
cases and in growths inclined to torsion, a radical operation is indicated. 
Schroder attempted to fasten movable tumors by sutures through the 
abdominal wall. Such a procedure is not only unsatisfactory, but danger- 
ous. The profuse hemorrhages which frequently occur require that the 
nutrition should be carefully maintained and that all excesses of Bacchus 
and venery should be avoided. Preceding and during the menstrual 
period the patient should be kept in bed and an ice-bladder or cold ap- 
plications should be placed over the abdomen. Tea and coffee should 
be interdicted, because experiments have demonstrated that both these 
beverages increase the hemorrhage. Various baths and mineral waters 
have been advocated as especially efficacious. Among these are the 
Kreuznach, Tolz, and Halle, in upper Austria, which are largely impreg- 
nated with iodin and bromin, and the Franzensbad and Elster, in which 
sulphur is an important element. These waters probably exert their in- 
fluence, not so much by their direct effect upon the tumor, as by the 
improvement of general nutrition. The health is built up, complete rest 
secured, the appetite improved, and more or less relief is obtained. 

Treatment may be: 

Medical. 

Electrical. 

Surgical. 



624 GYNECOLOGY. 

Medical treatment should consist in the employment of remedies 
and hygienic measures directed to promote the general nutrition of the 
patient and to ameliorate the unpleasant symptoms. Such treatment 
must be largely symptomatic. The list of remedies advocated for the 
treatment of uterine myomata is extensive: but, as usual, the larger the 
list of remedial agents, the less beneficial the influence exerted. Not- 
withstanding the effective results attributed to many different remedies, 
the history of myomatous growths discloses that normally they undergo 
peculiar changes, becoming sometimes larger and at others smaller. 
Occasionally the growth disappears without any assignable cause. Such 
fortunate results have added to the reputation of certain remedies, when, 
had they not been administered, a similar cure would probably have 
occurred. 

The agents most likely to exert an influence upon the progress of 
the growth are those which produce an effect upon the muscular coat of 
the organ, and belong to that class known as oxytocics, of which ergot 
is the principal. Ergot may be administered by the stomach, by the 
rectum, or by hypodermic injection. By the stomach it causes more 
or less disturbance of the digestive tract, nausea, and vomiting. More- 
over, in order to secure any beneficial effect it must be continued over a 
long period of time, which renders this method of administration ob- 
jectionable. Ergot in combination with a vegetable astringent will some- 
times exert a favorable influence in decreasing and arresting a severe 
hemorrhage. It may be employed in the following combinations: 

I^. Ext. ergot., ~ f oj 

Extract, hamamelis, 

Tinct. cinnamon., aa f oss. M. 

SiG. — f oj every two or three hours 

Or: 

^. Ergotin, gr. ij 

Hydrastinin. hydrochlorat., gr- i M. 

Ft. capsulse No. xxx. 

SiG. — A capsule to be taken every three or four hours. 

The fluidextract of cotton-root or an extract of ustilago maidis, the 
ergot of corn, acts similarly though less effective than ergot. When 
a patient suffers from expulsive efforts of the uterus, these may be 
ameliorated by the addition of extract of cannabis indica, gr. 1/4 to 
each dose. Ergot is most effective when administered by hypodermic 
injection, using either the sterilized fluidextract, the normal liquid, 
ergotin, or ergone. The agent should be thoroughly aseptic, should 
be injected in close proximity to the tumor, preferably in the abdom- 
inal walls, and the caution should be taken to make the injections 
deeply into the muscle, since they will then be less likely to cause abscess. 
Ergot acts in two ways: by stimulating the muscular coats of the 
blood-vessels, thus cutting off the supply of blood sent into the uterus; 
and, secondly, by increasing the activity of the muscular structure 
of the organ. Fibroid growths situated in the uterine wall are, by its 
influence, more readily expelled, either intraperitoneally or extraperitone- 



GENITAL TUMORS. 625 

ally. To be efficacious, the drug must be continued over a long period 
of time. When thus employed, it exerts an influence upon the muscular 
coat of the blood-vessels throughout the body, increases the danger of 
arterial sclerosis and the establishment of pathologic processes more se- 
rious than those for which the drug was administered. Among some of the 
other drugs having a reputation for producing alterations in retrogressive 
fibroids may be named the potassium and ammonium salts, particularly 
the bromid, the iodid of potassium, and the chlorid of ammonium. How 
much influence any of these drugs exert upon the progress of the disease 
is an undetermined question. Among other drugs that have been used 
are sulphuric and gallic acids, turpentine, cannabis indica, extract of 
hamamelis, extract of hydrastis canadensis, and the active principles 
of the latter, hydrastin and hydrastinin. While the latter agents exert 
a favorable influence by constringing the blood-vessels, and thus serve 
to control hemorrhage, this can be accomplished better by the administra- 
tion of cotarnin hydrochlorat gr. j fevery three hours. Efforts have been 
made to bring about the absorption or destruction of fibroid tumors to 
compensate for the deprivation of certain nutrient elements which enter 
largely into thp composition of the growth. A diet composed of the 
carbohydrates seems to have been in some few cases effective. Sir J. Y. 
Simpson, recognizing that the calcareous degeneration of a fibroid limited 
its further growth, purposed to accomplish this phenomenon by the ad- 
ministration of large doses of chlorid of calcium, but he soon found that 
this drug produced calcareous plates in the aorta and in the valves of the 
heart, and thus caused a graver condition than that for which it was given. 
In recent years the extract of thyroid gland has been advocated to reduce 
the size of growths and assist in the arrest of hemorrhage. As patients 
vary to a great degree in their susceptibility to the influence of this agent, 
it must, therefore, be employed carefully, increasing the dose gradually 
from one to three grains a day to the largest amount the sensibility of the 
patient will permit. In exophthalmic goiter, or in irritable conditions 
of the heart, the drug is badly borne, even in small doses. In some cases 
of fibroid growths I have found that the drug produced such an effect 
upon the nervous system that its use had to be discontinued. Bringing 
into action, as it does, the active principle of one of the internal secretions, 
it exerts an influence upon the lining structures of the uterus and thus is 
beneficial in lessening the tendency to hemorrhage. Polk and Mann 
claim to have seen pronounced effects from this drug in the diminution of 
the size of the tumor, but that it has any permanent influence is question- 
able. Hemorrhage may be lessened and opportunity given for coagula- 
tion of the blood in the uterine sinuses by reducing vascular tension, by 
the administration of glonoin and the nitrites. Probably the extract of 
the suprarenal gland or its active principle, adrenalin, is more effective 
than any other agent mentioned in stimulating the muscular coat of the 
blood-vessels, thus lessening the tendency to hemorrhage. Various local 
measures such as injections into the vagina, have been employed. These, 
however, can have no influence on hemorrhage from the uterus, as the 
coagulation of the blood in the vagina will be insufficient to afford any 
40 



626 GYNECOLOGY. 

obstruction to severe uterine hemorrhage. Ice-water was formerly em- 
ployed, later hot water. Both agents are efficacious in the field of ob- 
stetrics, but they have little influence upon fibroid tumors. The agent 
must come directly in contact with the affected endometrium to be of 
service. When hemorrhage is marked and uncontrollable by drugs and 
threatens the life of the patient, the vagina or even the uterine cavity 
should be packed with iodoform gauze, which acts as a tampon and thus 
controls the bleeding. When the uterine canal is opened, its cavity may 
be irrigated with hot water or vinegar and water, or a solution of per- 
chlorid of iron, tincture of iodin, or other agents for the purpose of arrest- 
ing hemorrhage. Sometimes these are quite effective for a length of time, 
but their use is not unattended with danger. The uterine canal should 
be so patulous that the subsequent drainage can be complete, but even in 
such cases the method of treatment is frequently attended with danger. 
I remember well a patient in my early experience who had a large fibroid 
tumor, which occasioned frequent attacks of profuse bleeding. The 
cervical cavity was quite patulous, and with a uterine syringe I injected 
tincture of iodin into its cavity. Almost before the syringe could be 
withdrawn the patient complained of tasting the drug. Within a few 
moments she had a most violent attack of pulmonary edema, which 
threatened her life, and she recovered only after a protracted illness. 
Moreover, this state was followed by prolonged mental disturbance. 
Needless to say, I have not been inclined to regard this plan of treatment 
with a great deal of confidence. 

Electricity has been used in the treatment of fibroid growths for many 
years. The methods for applying it were crude, and frequently were 
attended with great danger, especially when punctures were made through 
the abdominal wall directly into the tumor by an insulated needle, which 
thus produced a direct and localized influence upon the structure immedi- 
ately in contact with the poles. It remained for Apostoli, by his method 
of measuring the current and fixing the direct dosage, to evolve a plan of 
treatment which can be practised with a certain degree of precision. Un- 
der ordinary means the passage of a current of from five to ten, or at most 
twenty milliamperes is attended with considerable discomfort. By his 
apparatus and method of procedure from 100 to 200 milliamperes are em- 
ployed. He accomplished this by applying over the external surface a 
large, comparatively inactive electrode, while he introduced a more 
active electrode into the vagina, or preferably, into the uterine cavity. 
He further defined the influence of the positive and negative poles. The 
positive pole produced a decomposition of the fluids causing about it 
the accumulation of an acid, while at the negative pole it was alkaline. 
The former proved the more destructive in its influence, and hence is par- 
ticularly used in benign diseased conditions of the mucosa which cause 
hemorrhage. The positive pole within the uterus causes electrolysis 
or cauterization with coagulation of the blood in the vessels and arrest 
of bleeding. The negative pole, on the contrary, produces edematous 
infiltration of the tissues extending some distance about the electrode and 
the size of the growth decreases by absorption. In practising Apostoli's 



i 



GENITAL TUMORS. 627 

method are required: an electric battery sufficiently large to give a cur- 
rent strength of 200 to 300 milliamperes without its wearing out too rap- 
idly; a galvanometer capable of measuring 500 milliamperes; a rheostat, 
by which the current strength can be increased gradually. A current 
chooser is important. This is an instrument by which the current can 
be changed from positive to negative without removing the electrodes. 
However, the strength of the current must be reduced very greatly be- 
fore such a change is made as otherwise the patient would receive a vio- 
lent and painful, if not dangerous, shock. 

Electrodes. The external electrode should be placed over the ab- 
domen and may consist of the clay pad of Apostoli, the bladder or 
water electrode advocated by Martin, or of a towel wet with salt solution 
over which the electrode is placed. It should be large. The intra- 
uterine electrode may be a probe insulated within a couple of inches or 
more of its point. An ordinary probe with a gutta-percha hood which 
can be slid over it forms a convenient electrode. These are placed in 
position before the current is applied. The latter is introduced gradually, 
watching the galvanometer and the expression of the patient in order 
to ascertain her sensibility. The internal electrode is made of platinum 
or carbon as these materials have more endurance. Large quantities 
of strong acids accumulate about the electrode and the electrolytic 
action would destroy the less durable metals very quickly. The vagina 
should be cleansed thoroughly before electrical applications to avoid 
the introduction of infection into the uterine cavity. While electricity 
is a powerful antiseptic, it is only so in strong doses. Electricity may be 
given tw^o or three times a week, according to the intensity of the dose. 
When powerful currents are used, but one application a week is prefer- 
able. The seance should last from five to fifteen minutes. Before the 
application the skin of the abdomen should be inspected carefully for 
breaks in the corium, by denudation from scratching or from the presence 
of furuncles. Irritated points should be treated and excluded from 
contact with the electrode by collodion or pieces of plaster to insulate 
it. The external electrode, connected with the battery, is placed upon 
the abdomen. The internal electrode, also connected, is introduced, 
but with the precaution to have the current closed. The current is 
opened slowly and carefully, and is then increased gradually to the point of 
tolerance. Before the withdrawal of the electrode the current is gradually 
reduced, to prevent severe shock to the patient. In the initial treatment 
it is important to control the current carefully, and to use currents of 
moderate intensity, only, until the patient's toleration is determined. 
It is difficult to fix the number of applications to be required. Usually 
from twenty to thirty are sufficient. 

Electro puncture of the Myoma. Occasionally the situation of the tumor 
may be such as to displace the external os greatly, to render the canal 
tortuous, and make the introduction of the electrode difficult. In such 
cases the myoma may be punctured through the anterior cervical wall. 
The antisepsis should be as rigid for this procedure as for the most 
serious operation, and as it is quite painful, an anesthetic should be 



628 GYNECOLOGY. 

employed. The vaginal puncture from one-half to one centimeter deep 
is performed without a speculum. Care must be taken to avoid injuring 
the uterine artery, the bladder or the intestines. 
Electricity exerts its influence in three ways : 

1. In the diminution of the tumor from one-fifth to one-half of its 
original size. Complete disappearance is exceedingly rare. 

2. In a most marked influence upon the hemorrhage. 

3. In the relief of pain. 

The disappearance of pain and the arrest of hemorrhage necessarily 
improve the general condition of the patient. Apostoli gives the follow- 
ing contra-indications : i, hysteria; 2, intestinal catarrh; 3, pregnancy; 
4, malignant degeneration of the tumor; 5, fibrocystic tumors. 

Some of his followers do not consider hysteria an absolute contra-in- 
dication, but Apostoli has made the observation that the hysteric possess 
a great intolerance to the electric current, making it impossible during 
the course of a sitting to introduce a sufficiently high current to induce 
favorable results. In intestinal catarrh the current has a strong influence 
on the so'ar plexus, which calls forth severe contraction of the intestinal 
muscle. The presence of malignant growths must necessarily offer a 
direct contra-indication to electric treatment. The diagnosis sometimes 
is difficult to determine. 

Rapid growth in a myoma subsequent to the menopause indicates 
some degenerative process, possibly a malignant one, and electric treat- 
ment should not be given. In fibrocystic tumors the gas accumulation 
during the electric treatment may lead to suppuration. Gehrung, 
in such cases employs a puncture cannula, so that the fluid contents of the 
tumor can be drawn off. The presence of pus in the adnexa, as men- 
tioned by Apostoli, is a frequent complication and difficult to recognize. 
Electrical treatment in such cases is harmful without exception. It is 
not necessary that the inflammation should have reached suppuration 
in order to contra-indicate the treatment. Very acute or subacute in- 
flammation about the uterus is a positive contra-indication. 

Further, a very important contra-indication for electric treatment 
depends upon the situation of the tumor and its relation to the uterus, 
and justifies the following statement: 

(a) In subserous tumors, particularly when they are pedunculated, 
electric treatment will have but little beneficial effect, and is apt to prove 
injurious. 

(b) A pedunculated submucous fibroid affords no special advantages 
for electric treatment. 

In an inconsiderable number of cases suppuration of a polypus has 
resulted from intra-uterine electric treatment. Often the result has been 
fatal, or there has been total extirpation of the suppurating organ with 
or without favorable result. Additional contra-indications are heart 
failure or acute nephritis. Parsons asserts that hard tumors cannot be 
influenced by electricity. 

Colossal Tumors. In studying the influence of electricity upon the 
tissues of large growths, polar and interpolar action must be considered. 



GENITAL TUMORS. 629 

Polar influence depends incidentally on the electrolytic action in the 
soft tissues. In the transmission of the current from the metallic body, 
fluid destruction takes place in a salt solution and an acid is formed about 
the positive pole of the electrode, while the metal surrounds the negative. 
Similar changes occur in the tissues of the body, so that about the positive 
pole acid material, such as carbonic acid and chlorin, is set free. In the 
cathode watery material — the alkalies — are collected. It is asserted 
that these materials in the nascent state exert a strong chemic influence. 
Albumin is coagulated, the vessels are narrowed, and a hard, dry, brown- 
red slough occurs, while under longer employment the tissues are de- 
stroyed. About the negative pole a soft, succulent, glue-like, easily 
scraped-off white slough occurs, as if one had employed concentrated 
caustic potash. Consecutive hemorrhages may follow its continued use. 
The negative current is absorbent, and is much more painful than the 
positive. Investigations have demonstrated that the positive pole acts 
more on the cell germs or cellular tissue, and the negative upon the 
protoplasm. The latter is more diffuse, while the former has a sharper 
limitation. 

The Interpolar Method. Apostoli's critics assert that his methods 
are not without danger. The principal dangers for myoma operations 
are hemorrhages and sepsis, but radical operations present various 
series of dangers — embolus, pneumonia, ileus, and death from chloroform 
as well as the later disturbances of nutrition. When the advantages and 
disadvantages of electric treatment are considered, the investigator is 
forced to the conclusion that it should be confined to the uncomplicated 
cases, while those cases which threaten life should be subjected to opera- 
tive treatment. 

The surgical treatment of fibroid growths may be either palliative or 
radical, but we will consider the procedures under the two divisions of vagi- 
nal and abdominal, according to the route by which the tumor is most 
accessible and may most readily be subjected to treatment. 

VAGINAL PROCEDURES. 

The vaginal procedures consist in: 

1. Dilatation and curetment. 

2. Incision of the cervix. 

3. Incision of the capsule. 

4. Removal. 

a. Torsion. 
' b. Incision of the pedicle. 

c. Enucleation. 

d. Morcellement. 

5. Ligation of the vessels. 

6. Hysterectomy. 

The abdominal route includes: 

7. Castration. 

8. Ligation of vessels. 

9. Myomectomy. 

10. Enucleation. 

11. Supravaginal amputation or partial hysterectomv. 

12. Panhysterectomy, ■ 



630 GYNECOLOGY. 

311. Vaginal Procedures, i. Dilatation of the uterus may be in- 
dicated as the first stage in treatment of myomata or for diagnosis. 
Dilatation may be effected by the mechanical dilators of Hegar, but 
without tearing the neck they afford insufficient enlargement of the 
cervical canal to permit the introduction of the finger. The preferable 
method of dilatation is the employment of a laminaria tent, and the 
vagina should be cleansed thoroughly and rendered as nearly aseptic 
as possible before its introduction. The os is exposed by a Sims speculum 
or perineal retractor. The cervix is seized with a double tenaculum, 
the OS exposed, the plug of mucus filling the cervical cavity removed, 
and the canal thoroughly cleansed by mopping it out with cotton saturated 
with hydrogen dioxide after which as large a tent as can be introduced is 
selected, or, when the canal is pretty well dilated, a nest of tents may be 
used. Time can be saved by the introduction of several bougies pre- 
liminary to the insertion of tents. The larger number of tents which 
can thus be inserted permits the cervix to be so dilated by the first set 
that the uterine cavity can be explored by the finger upon their removal. 
These tents previous to their insertion should be sterilized by heating, 
placed for a few minutes before use in a saturated solution of iodoform 
and ether in a mixture of equal parts of carbolic acid and alcohol, or, 
better still, in tincture of iodin. After the introduction of the tent iodo- 
form gauze is placed beneath it to protect the parts from infection and 
to keep the tent from being extruded. Usually, at the end of twelve 
hours the cavity will be sufficiently dilated to permit the introduction of 
the finger. If the dilatation is insufficient, the canal can be enlarged by 
Hegar's bougies or with a second series of tents. The exposure by dila- 
tation permits the situation of growth and its size and relations to be 
recognized. The curet is used in a manner similar to that described in the 
treatment for endometritis. It should be done thoroughly to remove 
the hypertrophied mucous membrane. This removal of hypertrophied 
tissue ruptures and scrapes away the diseased vessels, and is effective in 
the arrest of hemorrhage. It should be followed by careful irrigation of 
the cavity, and subsequently by painting the canal with tincture of iodin 
or carbolic acid, or with a mixture of these two agents. When there 
is much hemorrhage following the use of the curet, the uterus should be 
packed with iodoform gauze. 

Curetment of the uterus, while effective in decreasing the hemorrhage, 
is not unattended with danger. The injury to the surface of the tumor 
may cause an inflammation, which will interfere with its nutrition, and, 
by the presence of germs which have been introduced during the proced- 
ure, may eventuate in suppuration and extensive necrosis. When myo- 
mata project into the uterine canal and the latter is irregular, difficulty 
is experienced in reaching all points of the canal with the curet, and the 
plan of treatment will not be effectual. In small tumors that cause severe 
hemorrhage curetment is of no value, and nothing short of the removal 
of the tumor will be of service. Indeed, I question the wisdom of the 
employment of the curet in any submucous or interstitial tumor for hem- 
vorrhage, as it is possible for the nutrition of the growth to become so 



GENITAL TUMORS. 



631 



impaired through the process of necrobiosis that such a formation of 
toxins is engendered as to affect the general health of the individual 
adversely. It is much better that the employment of tents should be- a 
preliminary to measures for the extirpation of the growth. 




Fig. 508. — Incision of Cervix to Expose Intra-uterine Myoma. 

2. Incision of the cervix is another palliative measure. (Fig. 508.) 
It consists in making a bilateral or an anteroposterior incision through 
the cervix, which diminishes its resistance and facilitates the extrusion of 



032 



GYNECOLOGY. 



the tumor. When the body of the uterus is well dilated by the growth, 
this procedure permits the' tumor to be extruded more rapidly into the 
vagina, and it is thus rendered more accessible. It was formerly prac- 
tised very generally as a preliminary to the administration of ergot, but 
not infrequently the rapid separation of the tumor thus induced led to 
gangrene or necrosis of the growth and to fatal infection of the patient. 
Incision of the cervix will frequently prove of value as a first step in op- 




I 



Fig. 509. — Cervix and Capsule Incised, the Latter Pushed Back. 

erative procedure for the removal of a growth, and its employment should 
be limited to such instances. 

3. Incision of the Capsule (Fig. 509). In sessile submucous or intersti- 
tial fibroids which project into the cavity of the uterus the more rapid expul- 
sion of the tumor can be accomplished by incising the uterine surface of 
the tumor into and through its capsule. The incision is accomplished 
by wrapping the blade of the knife with adhesive plaster at a necessary 
distance from the point, as advocated by Atlee, or the thermocautery or 



GENITAL TUMORS. 



63. 



galvanocautery knife can be employed. The wall is pushed back and 
the tumor partly enucleated, which decreases the resistance. Subsequent 
contraction promotes the extrusion of the tumor into the uterine cavity and 
renders it a pedunculated growth. This operation, though apparently 
but a slight one, is not free from danger, for the rapid extrusion which 
follows its performance not infrequently causes loss of vitality of the tu- 
mor and degenerative processes which may be dangerous to the life of 
the patient. The procedure is advisable only when it is used as one of the 
preliminary stages for removal of the growth. 

4. Removal of the Growth. — a, Torsion (Fig. 510). When the growth is 
situated in the vagina, after having been extruded from the cavity of the 
uterus, and hangs by a p.edicle, it can be removed readily by torsion. The 




Fig. 510. — Removal of Myoma by Torsion of Its Pedicle'. 

technic of the procedure consists in placing the patient in the dorsal posi- 
tion and expos 'ng the tumor (after thorough asepsis) with an Edebohls 
speculum or with retractors. The growth is seized wdth a strong vulsel- 
lum forceps, preferably four-bladed, and turned upon its axis until the 
pedicle of the tumor is twisted off. When such forceps are not at hand, 
the same purpose can be accomplished by seizing the tumor upon opposite 
sides with double tenacula and rotating it by traction with these instru- 
ments. When the tumor has not been extruded from the cervix, the os 
can be enlarged by a bilateral incision until the intra-uterine tumor is 
exposed, when it can be removed, if the tumor is pedunculated, in the 
manner described. 

h, Incision of the Pedicle. W^hen the tumor has been extruded from 
the uterine cavity, it may be seized and dragged upon with a pair of forceps 
until the finger can be passed over it as a guide, when with a pair of scis- 
sors (Fig. 511) the pedicle can be cut; or the intra-uterine tumor can be 



634 



GYNECOLOGY. 




Fig. 511. — Incision of Pedicle of Myoma. 






Fig. 512. — Enucleation of Tumor through the Vagina. 



GENITAL TUMORS. 



635 



rendered accessible by dilatation with tents, or through bilateral incision 
of the cervix. The employment of the wire ecraseur or the galvano- 
cautery wire is advocated by some for cutting the pedicle, but any hemor- 
rhage likely to occur can be controlled by gauze packing, and the proced- 
ure lessened beyond the danger of hemorrhage, affords no advantage 
to compensate for the extra loss of time. In all these operations rigid 
asepsis must be practised. 

c, Enucleation was first practised upon submucous fibroid growths 
of the sessile variety. Here, when or after the uterus is dilated, the tumor 




Fig. 513. — Interstitial Tumor Exposed by Vertical Incision of the Anterior Lip. 

is exposed, seized with a pair of forceps, drawn upon, and, with the finger 
or a blunt dissector, the attachment to the uterus is broken and the tumor 
removed. Thomas employed a serrated spoon which hugged closely 
to the surface of the tumor and pushed away the uterine wall. (Fig. 
512.) This spoon, however, is not without danger in cases in which 
the uterine wall overlying the tumor is thin. The enucleation can be 
accoinplished as readily with a blunt dissector. The tumor should 
be rolled about during the procedure so that the surface to be sepa- 
rated is constantly under observation. When the tumor for enuclea- 



636 



GYNECOLOGY. 



tion is within the body of the uterus, the finger should be used as a guide. 
Interstitial tumors may also be removed in a similar way. If necessary, 




i 



Fig. 514. — Myoma of x\nterior Wall Exposed by Transverse and Vertical Incision. 

the cervix may be split by a bilateral incision through the internal os as 
a preliminary. An interstitial tumor of the anterior wall may be made 
accessible by a vertical incision through the anterior lip until the base of 



GENITAL TUMORS. 



63; 



the tumor is exposed, when it is seized and the tissue bluntly dissected 
away from it. (Fig. 513.) Occasionally, when the cervix is undilated and 
the tumor is in the anterior wall, it may be exposed by a transverse in- 
cision above the cervix, and subsequently by a vertical cut at right angles 
to the former (Fig. 512). The flaps are turned back, after which the 
tumor is enucleated. WTien necessary, the bladder should be dissected 
from the anterior surface of the uterus until the peritoneum is reached, 
and the latter can be opened. Retro-uterine tumors are made acces- 




-]Myoma of Posterior Wall Exposed by Retro-uterine Incision. 



sible through a posterior vaginal incision, which will permit the fundus 
to be rotated backward. Through this opening the enucleation is ac- 
complished and the line of incision carefully closed by sutures before the 
organ is returned to its normal position. (Fig. 515.) 

d, Morcellement. Xot infrequently, as we proceed in the enucleation 
of these growths, it will be found that a tumor is so large that we are unable 
to complete our enucleation or to deliver the tumor through the vagina. 
In such cases the tumor may be reduced in size by the process described by 
the French as morcellement, which consists in cutting out sections of the 



638 



GYNECOLOGY. 



mass with scissors or knife, and working up on one side until the tumor 
can be drawn down and the remaining portion completely enucleated. 
It frequently can be accomplished by dividing the tumor into -halves, 
quartering it, or cutting off small sections of the accessible portions with 
scissors or knife until the entire mass is removed. 

The principle of morcellement is applied to the removal of the uterus 
as well as to extirpation of morbid growths. The object is to insure the 
reduction of the size of the organ until it can pass through the vagina 
readily. It consists in splitting the cervix by vertical incision, then remov- 
ing wedge-shaped masses from each side. Avoid nearer approach than 
one-half inch to the lateral surfaces of the uterus. During the procedure 




Fig. 516. — Removal of Myoma by Morcellement. 

the parts are made tense by traction upon the mass with a double tenac- 
ulum. (Fig. 516.) Care must be exercised to secure a new grip upon 
the remaining portion before any piece is excised. Upon the com- 
pletion of the delivery of the uterus, hemostasis is accomplished as in 
hysterectomy, which will be described later. After removal of the growth 
by enucleation there will remain a considerable cavity, lined by tissue of 
low vitality, which should be cleansed thoroughly, packed loosely with 
iodoform gauze, and the patient watched that no renewal of bleeding 
occurs. The gauze packing prevents accumulation of blood in the 



GENITAL TUMORS. 639 

Uterine cavity, keeps the surfaces separated, promotes the sealing of the 
surfaces by plastic exudate, and, by its presence as a foreign body, favors 
contraction of the remaining portion of the uterus. In three days the 
gauze should be removed, the cavity irrigated thoroughly, and the uterus 
repacked, or a drainage-tube inserted, through which irrigation can be 
practised subsequently. When the cervix has been incised, the wound 
should be sutured as in an operation for lacerated cervix. All incisions, 
whether bilateral, through the anterior lip, or in the wall of the uterus, 
should be closed by suture. 

5. Ligation of the Vessels. The usual observation that myomata de- 
crease in size with the cessation of the periodic congestion of the uterus 
at the establishment of the menopause induced Gottschalk and Martin 
to endeavor to decrease the blood-supply to such growths and thus avoid 
the necessity for sacrificing the function of procreation. Gottschalk 
was the pioneer in vaginal operations for this special purpose. He limits 
the operation to extraperitoneal tumors, and in seven years found but 
twenty cases in which it was applicable. Of sixteen of these, which 
continued under observation, decrease in pain and hemorrhage was ex- 
perienced by the majority. In a few the good results were delayed. 

The treatment is as follows: The patient is placed in the lithotomy 
position, the uterus explored, and any submucous myomata removed, 
followed by cureting as a routine measure. A circular incision in front 
of the cervix is prolonged as far as its posterior surface. The bladder is 
bluntly dissected from the uterus and broad ligaments and the vaginal mu- 
cosa loosened upon each side posterior to the broad ligament. The uterine 
artery and its branches are palpated and secured by three chromic catgut 
ligatures upon each side, which are cut short and buried by vaginal suture 
of the mucosa. The operation is followed by severe pains, and a few days 
later by a cast of the endometrium. In but three instances did the first 
menstruation occur at the normal period. Franklin Martin pursued the 
following course: With the patient in the lithotomy position he dilated, 
cureted, irrigated the uterus with i : looo bichlorid solution, and packed it 
loosely with iodoform gauze. He pulled the cervix to one side, made a 
lateral curvilinear incision over each uterine artery, and pulled the bladder 
away from the anterior surface of the broad ligaments for over two inches, 
while the latter wxre partially isolated upon their posterior surfaces. 
The vessels were recognized and guarded by the finger, a ligature was 
passed upon each side, and the ends were cut short. Care had to be 
exercised that a ureter was not included in the ligature. He advised that 
in large tumors the broad ligament should be spread out still further and 
the ovarian artery upon one side seized and ligated. The ligated tissue 
was buried by suturing the vaginal mucosa, and the vagina was packed 
loosely with iodoform gauze. Both the vaginal and uterine packing were 
removed at the end of two days and bichlorid douches given subsequently. 
This confines the future blood supply of the tumor to one ovarian artery. 
Martin found that this plan of treatment resulted in arrest of hemorrhage 
and decrease in the size of the growth. The main objection to this plan 
of treatment is the possibility that in the ligation too much of the supply 



640 GYNECOLOGY. 

of blood may be cut off, and cause a loss of vitality and subsequent 
necrosis of the growth, which will greatly increase the danger to the 
patient. 

6. Hysterectomy. Removal of the uterus with the offending growths 
can be done with advantage through the vagina when the latter is large 
and roomy and the uterus is not too large and is freely movable. The 
operation should not be considered when the growth extends higher than 
midway to the umbilicus, when the broad ligaments are occupied by 
growths, or when the growths affect the nulliparous woman. There are 
two principal methods of operating: i, The removal of the uterus without 
section, and 2, division of the organ in order to reduce its bulk. The 
first procedure bears the name of Pean. The technic as modified by 
present methods is as follows: The patient is placed in the lithotomy 
position; the vagina is scrubbed with tincture of green soap, with sterile 
water and with alcohol; the cervix exposed with retractors; and the 
plug of mucous wiped from the external os. The cervix is seized with 
strong forceps, or, where it is desirable to prevent discharge from the 
cavity, the cervix may be closed with sutures which will serve as tractors 
if left long. It is separated from the vagina by an oval or circular in- 
cision carried nearer the os in front than behind. This incision may be 
made wdth knife, scissors, or thermocautery. The finger or a blunt 
instrument dissects the bladder from the uterus and broad ligaments, 
and at the same time the ureters are pushed back. After posterior dis- 
section has been accomplished in the same way and the peritoneum opened 
in front and behind, the uterus remains attached only by the broad 
ligaments. The uterine artery is exposed, ligated on either side with 
chromic catgut and cut between the ligature and the cervix. The ends 
of the ligature are cut short to prevent the danger of subsequent traction 
pulling the ligature from the vessel. The fundus is turned down through 
the anterior vaginal fornix and as traction is made on it, the broad liga- 
ments are rendered tense, permitting the relations of the tubes and 
ovaries to be determined more readily and existing adhesions separated. 
The broad ligament, preferably on the left side, is securely ligated, 
clamped above the ligature with hemostatic forceps and the broad liga- 
ment cut between the ligature and the appendages. Readier access is 
thus afforded to the right broad ligament which is treated in a similar 
manner. The cut surfaces are carefully inspected for bleeding vessels 
which are at once secured, and the peritoneum front and back united to 
the vaginal walls. From either side a suture is carried through the an- 
terior vaginal wall and peritoneum, the stump of the broad ligament 
above the hemostat, through the posterior wall from the peritoneum out 
and securely tied above the hemostat which is then removed. While 
the external angle of the incision in the vagina is held the stump of the 
broad ligament is pushed behind it and the vagina sutured. Thus 
both the peritoneum and the vagina are closed so that no raw surfaces 
present in either. Ligatures for vessels and securing the stumps in the 
angles of the wound should be chromic catgut; those uniting the perito- 
neum to the vagina and closing the latter, of plain catgut. 



GENITAL TUMORS. 64 1 

It may be necessary to vary this procedure to meet special indica- 
tions, as the growths may be so large as to require their enucleation pre- 
liminary to turning down the fundus; or it may be necessary to bisect 
the uterus and remove each half of the organ separately. If still too 
large for delivery portions of the organ and the growths may be removed 
until its size is sufficiently reduced to permit of its withdrawal. AVhen the 
tubes and ovaries are the seat of suppurative conditions which make it 
inexpedient to close the wound, the cavity should be packed with iodoform 
gauze and treated as an open wound. Clamps may be employed in the 
place of ligatures. This is a more expeditious procedure, but in addition 
to the foul wound from the sloughing tissue included in the clamps, 
hemostasis is not as secure. Schauta lost seven out of forty cases with the 
use of clamps, chiefly from secondary hemorrhage after their removal. 
Convalescence is greatly delayed by necrosis of the clamped portion of the 
ligament. Bishop reported eight hundred and thirty-six cases of vaginal 
hysterectomy with twenty-nine deaths, a mortality of 3.4 per cent. Some 
operators pride themselves on being able to remove per vaginam growths 
which extend to the umbilicus, but such a course is attended with so much 
increase of danger as to render it an unjustifiable procedure. 

312. Abdominal Route. 7. Castration. As early as in 1872 
Hegar advocated the removal of the ovaries to establish premature 
menopause in order to accomplish reduction in the size of fibroid growths. 
This procedure was devised in recognition of the fact that fibroid tumors 
generally decrease in size with the establishment of the climacteric. 
The operation consists in the removal of the ovaries and tubes or the per- 
formance of oophorectomy. It was found, however, that the removal of 
these organs was not infrequently attended with great difl&culty, as the size 
of the growth led to a vascular condition of the broad ligaments, and often 
the ovary was spread out upon the surface of the tumor, which rendered 
its enucleation and removal exceedingly dangerous; sometimes the tumor 
rotated in such a way as to carry one ovary posterior, rendering it abso- 
lutely inaccessible without reduction of the size of the tumor. Moreover, 
the ovary might be wedged between two multinodular growths, whence it 
could not be removed without injury to both. Moreover, the procedure 
was not always successful, as many patients who were victims of fibroid 
growth continued to menstruate or to have a bloody discharge subsequent 
to the removal of both ovaries. This is due probably to the fact that the 
ovarian stroma extends along the course of the ovarian ligament, and 
the ordinary method of procedure did not remove the entire ovarian 
structure. So long as any portion of the ovary remained to mature and 
throw off ova, just so long would bleeding from the uterus occur. Tait 
advised the entire removal of the Fallopian tubes as a sure method of 
establishing the climacteric, attributing the influence dominating menstrua- 
tion to these organs. The advantage of this suggestion doubtless was that 
the ligature was carried deeper and the ovarian arteries ligated, as they 
had escaped this in the more superficial ligation. To insure ligation of the 
artery it is recommended that the ligature be placed sufficiently deep to 
include the round ligament. The advantage of castration is that in 
41 



642 GYNECOLOGY. 

typical cases it can be done in a few minutes with slight danger; but, 
unfortunately, in large fibroid growths the ovaries are not always typically 
situated. In considering this operation then, the situation of the ovaries 
and their relation to the growth should be examined to ascertain whether 
both ovaries can be removed completely. The removal of one would ex- 
ercise no beneficial influence on the progress of the growth nor would it 
correct abnormal symptoms. Occasionally, the tumor causes torsion 
of the uterus, by which one ovary is moved toward the front and the 
other behind the tumor in such a situation that it cannot be reached; or, 
as noted, the ovary can be so intimately connected with the surface of 
the tumor that any attempt to enucleate or remove it would be attended 
with more serious hemorrhage than would be occasioned by the removal 
of the growth. Another objection to castration is that it does not always 
control the hemorrhage. In the performance of the operation it is 
absolutely necessary that every portion of both ovaries should be removed. 
The smallest amount of ovarian tissue remaining insures the continuation 
of the hemorrhage. When the fibroid is large, entire removal is frequently 
attended with the greatest difficulty, as the adherent ovarian stroma can- 
not be separated readily from the surface of the tumor. The operation 
is still further complicated by the existence of tubal diseases, such as 
pyosalpinx, in which extensive adhesions bind together the ovaries, 
tubes, and tumor in one mass, so that castration will be attended with 
greater obstacles and danger than would be associated with hysterectomy. 
Castration should not be considered in cases of pure submucous myoma 
or in cystic degeneration of the fibroma. In pedunculated subserous 
and adherent tumors, and in very large interstitial growths, it is also 
contra-indicated. In a freely movable uterus, in which the cervix can be 
reached readily, the operation affords no advantages over supravaginal 
amputation. Frequently castration has a further disadvantage in pro- 
ducing vasomotor symptoms, such as congestion, sweatings, hot flashes, 
or pain in the head and sacrum. These symptoms are worse in the young 
than in those who are near the climacteric. Other symptoms are rather 
more rare, as obstinate vertigo, profuse leukorrhea, cardialgia, and 
occasionally vicarious bleeding. 

8. Ligation of the Vessels. The operation of castration having demon- 
strated the beneficial influence of ligation of the ovarian arteries, it was a 
natural step to proceed to ligation of these vessels through the abdom- 
inal incision in preference to the more radical operations of partial or 
complete hysterectomy. Hofmeier reported a case of Schroder's in which 
extirpation of the myoma seemed impossible, and in order to decrease the 
size of the tumor, the lateral and median vessels of the ovary were tied, 
with good result. Antal, at an earlier date, after ligation of the vessels 
observed an atrophy of the ovary, and, in place of castration, thereafter 
employed incidentally the mere ligation of the vessels in order to affect 
the function of the ovaries. Byron Robinson advocated the ligation 
of both ovarian arteries and the upper part of the uterine artery at the 
side of the uterus. This procedure is more effective in the smaller 
growths, or where hemorrhage is a marked symptom. 



GENITAL TUMORS. 



643 



9. Myomectomy. In more or less pedunculated subperitoneal fibroids 
there should be no question as to the advisability of myomectomy. 
When the pedicle is small, the operation consists in cutting through it 
with scissors or knife and uniting the edges of the cut surface with sutures 




Fig. 517. — Abdominal Myomectomy. 




Fig. 518.— Abdominal Enucleation of Myomata and Method of Closing the Uterine Wound. 

so deeply placed as to make sufficient pressure to control bleeding. 
(Fig. 517.) When the pedicle is not large, its peritoneal covering should 
be cut through by the circular incision, turned down like a cuff, the 
base of the pedicle ligated with chromic catgut and the tumor cut away, 



644 GYNECOLOGY. 

after which the peritoneal cuff can be united over the stump. In larger 
pedicles the operation consists in making peritoneal and muscle flaps, 
which can be sutured. Thus a single growth or a number of growths 
may be removed, leaving a normal uterus and the ovaries and tubes 
undisturbed. 

lo. Enucleation. The ease with which smaller fibroid growths can 
be enucleated from their beds has led to the practice, by Martin and 
others, of shelling out interstitial fibroid growths from the uterine wall, 
leaving the uterus in place. (Fig. 518.) The procedure is as follows: 
The uterus is raised up, the position of the growths determined, and an 
incision made over the more prominent growths in a vertical direction 
in order to injure as few vessels as possible. Incision is made into the 
uterine wall through the capsule, and the tumor exposed. It is then 
seized with a double tenaculum and drawn up, while the tissues are pushed 
off with a blunt dissector and the enucleation accomplished. The 
removal of the tumor is followed by packing a gauze pad firmly into its 
cavity. If large vessels bleed, they should be seized and controlled with 
pressure forceps. The wall is still further investigated, and, when pos- 
sible, other fibroid growths situated within it should be brought through 
the first incision. In some cases, however, this may involve more extensive 
mutilation of the uterus than a separate incision over the mass. 

Advocates of this procedure generally limit it to cases in which few 
.growths are found in the uterine wall, and formerly it was directed par- 
ticularly that the uterine cavity should not be opened. When, however, 
we consider the investigations of Menge and Kjronig, which demonstrate 
that the uterine cavity is free from pathogenic germs, there should be no 
Iiesitancy in opening it, if necessary, to remove growths. In one patient 
I thus enucleated thirteen fibroids from the wall of the uterus, five of which 
were removed from the uterine cavity. After the operation the patient 
recovered without a single abnormal symptom. From another woman 
nine growths were removed. In another woman (unmarried) twenty 
growths were enucleated. What remained of the uterus was pretty well 
riddled, but it was sutured together and the patient recovered completely. 
In an unmarried woman nine growths were removed, five of them from 
the anterior wall. The loose tissue, being of low vitality, subsequently 
became necrotic, and in the sixth week after the operation this was with- 
drawn through a sinus in the abdominal wound; subsequent convalescence 
was rapid. In an unmarried woman, a fibroid, projected into the cavity 
of the uterus, filled it up so that the tumor could be touched through the 
cervix. This was enucleated through the abdominal cavity by posterior 
uterine incision. A gauze drain was passed through the cervix and the 
uterus closed over it. The patient recovered. After enucleation of 
growths, the gauze inserted temporarily should be removed, and uterine 
wounds sutured carefully by deep and superficial layers of chromic 
catgut, exercising the precaution to include and secure with the suture 
any large vessels in the wall which may bleed, and by the superficial 
suture to bring a good portion, of the peritoneal surface in apposition. 
Before closing the abdomen all the wounds must be inspected thoroughly 



GENITAL TUMORS. 645 

to see that hemorrhage is controlled completely. Should there be a 
tendency to excessive bleeding, it would be better as an additional safe- 
guard to ligate the ovarian arteries. This operation is unsuitable for 
very large growths where the uterus would be extensively mutilated, 
or where the tumors are situated laterally and involve to a greater or less 
degree the Fallopian tube. In enucleation of intraligamentary growths 
the broad ligament is split, in order to expose them. In these cases 
care must be exercised that the ureter has not been displaced upward. 
It is important, also, to avoid injury to the ureter or its ligation in the 
subsequent closing of the broad ligament. 

II. Partial hysterectomy, or supravaginal amputation of the uterus y 
was the earliest abdominal operation for the removal of myomatous 
growths. The earlier operations were performed in cases of mistaken 
diagnosis, having been undertaken for the removal of ovarian tumors. 
The first deliberate operation seems to have been performed by Burn- 
ham, of Lowell, in 1853. The patient recovered. A large proportion of 
the earlier operations were unsuccessful; the difficulty in controlling hem- 
orrhage from the elastic stump rendered its intraperitoneal treatment 
exceedingly dangerous, so that the plan was practised of treating the 
stump extraperitoneally. The first surgeon to devise a systematic pro- 
cedure was Koberle, of Strasburg. His method was as follows: The 
patient was placed in the dorsal position, and a long abdominal incision 
made in the median line, through which the uterus and tumors were 
delivered. The peritoneum above the bladder was incised and the 
latter stripped down, an elastic ligature or serre-noeud was placed about 
the cervix as low as possible, and pins were passed through it above the 
serre-noeud. The uterus and tumors were cut away above the pins, leaving 
enough to prevent traction of the stump from the -grip of the instru- 
ment; the abdominal wound was closed down to the stump, while the 
latter was subjected to cauterization; and an application of persulphate 
of iron or tannin made to its raw surface to secure mummification. By 
some operators the parietal peritoneum was fastened to the peritoneal 
covering of the stump by a continuous catgut suture. This procedure was 
done to promote the rapid union of the peritoneal surfaces and thus pre- 
clude the possibility of discharges from the sloughing stump gravitating 
back into the peritoneal cavity. 

Occasionally, under this plan of treatment, the stump would become 
dry and gradually be thrown off without suppuration. However, the re- 
traction of the stump resulted in an excavation which had to close by gran- 
ulation, prolonging convalescence. Often it was difficult to prevent 
putrefactive changes resulting in suppuration. The weakened abdomen 
favored the subsequent development of ventral hernia. The difficulty 
in maintaining asepsis, the delayed convalescence, and the weakened 
abdominal wall, led to the study of methods by which the stump could be 
treated within the peritoneal cavity. One of the earliest operators to 
attempt the intraperitoneal treatment was Schroder, who published in 
1880 an account of his cases. He made a median incision, ligated that 
portion of the broad ligament containing the spermatic arteries with two 



646 GYNECOLOGY. 

ligatures, and cut between them. A similar course was pursued with 
the round ligaments. The peritoneum was cut across and the bladder 
pushed down. The stump, consisting of the cervix, was constricted by a 
rubber ligature, the mass cut away above the ligature, the stump caught 
with vulsellum forceps before the division was completed, and the cervical 
cavity cauterized with a 10 per cent, solution of carbobic acid. The di- 
vided surfaces were united near the mucous membrane with sutures; the 
raw surface quilted in with several rows of suture, and, finally, the peri- 
toneum was sutured over the stump, after which the rubber ligature 
was removed. He employed carbolized silk, and later juniper catgut, 
for sutures. Other operators have modified this procedure, as Zweifel, 
with partition ligature, and H. O. Marcy, with cobbler suture. Gow 
makes the following modifications : After delivery of the tumor through 
a median abdominal incision he ligates each round ligament on a level 
with the internal os, marks out an anterior peritoneal flap, and divides 
the round ligament and the anterior portion of the broad ligament between 
the uterus and the ligatures with scissors, carrying the incision toward 
the middle of the Fallopian tubes. The anterior flap is stripped down, 
the ovarian vessels and the Fallopian tubes enucleated and tied, so that 
at least one ovary is left. The broad ligaments are divided on the uterine 
side of the ligature, and bleeding from vessels connected with this portion 
may be controlled temporarily by clamps. He then marks out a posterior 
flap and dissects it downward for a short distance, seizes the uterine 
arteries with pressure forceps at the level of the os internum, cuts the tumor 
away with a knife, seizes and draws up the stump with vulsellum forceps, 
ties the uterine arteries, inserts a precautionary ligature by thrusting 
needles armed with silk through the stump from before backward, avoid- 
ing the peritoneum, so as to include the outer portion of the stump. This, 
done upon both sides, controls oozing or spurting from vessels which may 
have been given off obliquely. The bleeding area also may be encircled 
with a ligature passed by a needle. Two anteroposterior sutures are in- 
troduced through the muscular surface of the stump, avoiding the peri- 
toneum; the raw surfaces, as a rule, are sewed together, the peritoneal 
flaps united, the peritoneum cleansed, and the abdomen closed. Baer 
modifies this operation. He places the patient in the Trendelenburg pos- 
ture, and after separating the adhesions the tumor and uterus are de- 
livered through an abdominal incision, gauze is placed front and back, 
and each broad ligament is transfixed by a single silk ligature, which, 
when tied, controls the ovarian arteries and veins. The ligated parts 
are then severed external to the tube and ovary, incision being carried 
close to the cervix. The peritoneal reflection anterior to the uterus is cut 
through with scissors, the bladder stripped down with the handle of the 
scalpel, the uterine artery tied close to the cervix on each side and the 
cervix amputated just above the vaginal attachment. A small posterior 
fold is formed by stripping up the peritoneum while the amputation is 
made. The stump is now held in the grasp of tenaculum forceps. When 
the main arterial branches have been ligated properly, the raw end of the 
cervix will remain dry. (Fig. 519.) When all bleeding has been con- 



GENITAL TUMORS, 



647 



trolled, the peritoneal folds are adjusted loosely over the stump with 
Lembert sutures and the abdominal incision is closed. (Fig. 521.) The 
occasional accumulation of blood or serum beneath the peritoneum over 
the stump and its infection, by the formation of a cellulitis or pus-collec- 
tion, may delay convalescence. Le Bee, after abdominal section, draws 
out the uterus and fibroids, ligates the broad ligament with a double 
ligature, and severs it between the ligatures. The round ligaments are 
ligated separately and the bladder with the peritoneal flap dissected down 
into the vagina. The tumor may be decreased in size by throwing a 
rubber ligature around the cervix and cutting away the mass above, 




Fig. 519. — Supravaginal Removal of Myomatous Uterus. 



or the tumor can be drawn over the pubes, a long curved forceps inserted 
into the vagina so that, when opened two or three centimeters, the poste- 
rior fornix is stretched. A small incision is made into the pouch of Doug- 
las, and widened by opening the forceps. The tumor is drawn back and 
forceps are introduced so as to protrude against the anterior fornix, when the 
latter is treated in the same way. Care must be exercised, however, not to 
rotate the tumor to one side and thus injure the large uterine veins. 
One end of a long silk thread is seized by forceps, carried into the vagina, 
and brought up again through the opening in Douglas' pouch. Another 



648 



GYNECOLOGY. 



thread is applied similarly on the opposite side. Both are tied, thus con- 
trolling the uterine arteries. The tumor is removed horizontally just 
above the ligatures, and leaves only a pedicle which is split in the median 
line and as much cut away from each side as possible, leaving only enough 
to hold the ligatures. The long ends of these are seized with the forceps 
and drawn downward, the peritoneal flaps sutured together with catgut, 
and the abdomen closed. The Pyror- Kelly modification of the operation 
consists in the ligation of the ovarian vessel and round ligament and the 
division of the ligament upon one side. An anterior peritoneal flap is 
formed and the peritoneum and bladder stripped down. This exposes 
the uterine artery and veins, which are ligated by a ligature carried with a 



\ 




Fig. 520. — Cervix Cut Across Preliminary to the Complete Ligation of One Ligament. 

curved needle beneath them close to the side of the uterus, the organ is 
drawn to the opposite side, and the uterine vessels are divided. The 
uterus is cut across just above the vaginal junction. A pad of gauze is 
placed beneath the upper cut surface to prevent the intra-uterine dis- 
charges from escaping on the wound while the canal below is wiped out. 
When near the opposite edge of the cervix, the incision is carried up one 
to two centimeters so as to leave a thin shell of cervical tissue and to ex- 
pose the uterine vessels at a higher level, where they can be tied more 
easily and with less risk of including the ureter. The uterine vessels are 
clamped and divided, the uterus is rolled over still further, the round 
ligament clamped and cut through. With still more traction the ovarian 



GENITAL TUMORS. 



649 



vessels come into view, when they are clamped and cut and the whole 
mass becomes free. All clamped vessels are then tied. Kelly ties all 
important vessels twice — once during the enucleation and again after it 
is completed. The more expeditious procedure is to secure all vessels 
with clamps, separate the uterus and then proceed to the ligation. After 
control of the hemorrhage, the peritoneum is closed over the cervical 
canal by three to five catgut sutures. A lateral suture is passed on 
each side through the peritoneal surfaces and the broad ligament close 
to the cervix. The stumps of the broad ligaments are drawn into this 
and tied, thus securing the ovarian vessels by an additional ligature. 
The intervening peritoneal surfaces can be united by a continuous catgut 
suture, which should pass through the ends of the stumps to afford 
security against their being retracted. Where a large space has been 











h 




/ '' 








yi 






'J 


f 

jl 




\ 










'-3 


5r/ 





Fig. 521. — Stump Covered with Peritoneum. 

left in the cellular tissue, it is advisable to unite the peritoneum with 
interrupted or mattress sutures, so that blood can run into the per- 
itoneum and be absorbed instead of forming a hematocele. Bishop 
modifies the operation by removing the cervix entire. When the broad 
ligament is ligated, having reached the stage of ligation of the uterine 
artery upon one side, instead of cutting across the cervix he has an 
assistant push up the lateral culdesac of the vagina and cuts down 
upon it, and thus enters the vagina. With the scissors the vaginal wall 
is then cut through entirely around the cervix, which is bodily lifted up 
with the rest of the uterus and rolled over toward the opposite side. The 
cervix is seized with strong forceps and pulled up against the free surface 
of the uterus. It has been plugged previously and, consequently, gives 
no trouble from the discharges. He draws down into the wound a roll 
of iodoform gauze and closes the peritoneum over it. The abdomen is 
closed without drainage. This procedure affords a ready method of 
enucleating intraligamentary fibroids, especially if they are situated upon 



650 GYNECOLOGY. 

one side of the abdomen. The entire removal of the uterus has another 
advantage, as there is no obstacle to drainage from the pelvis. E. C. 
Dudley claims that the union of the peritoneal flaps by transverse sutures 
permits the pelvic floor to sag down. Therefore he advocates the union 
of these surfaces by an anteroposterior line of suture. Where the cervix 
is left, a flap is made on each side. These are united, and over them the 
peritoneal flaps are drawn and secured by an anteroposterior line of su- 
tures. The study of the evolution of any operative procedure would lead 
us to think that the originators of the plan studied to make it difficult. 
The constant aim of the operator should be to simplify procedures to 
secure the greatest expedition in the completion of the operation com- 
patible with safety. Where the sides of the pelvis are equally accessible, 
the operator may prefer to proceed from above on each side. The vessels 
can now be secured, making sure that hemostasis is effective, after 
which the peritoneal flaps are united and the abdominal wall closed. 

An effort has been made in the foregoing pages to present to the stu- 
dent a resume of the various procedures for the treatment of myomatous 
growths of the uterus in order, that when he comes to treat the patient, he 
may not be doubtful as to which method may be most applicable. I feel 
it but proper to indicate what I believe to be the preferable method. The 
operative procedure just described affords a ready method for dealing 
with those intraligamentary tumors which occupy only one side of the 
pelvis, but where we have the uterus filled up with fibroid growths ex- 
tending into the broad ligaments upon both sides and we cannot reach 
Douglas' pouch posteriorly, the problem for removal seems a most com- 
plicated one. The operation in such cases, can be performed expedi- 
tiously by making a vertical section through the uterus and tumor from 
the fundus downward, dragging the masses to either side as the incision is 
made. The intestines, of course, are held back by gauze introduced be- 
hind the tumor, while the bladder is rendered visible as we proceed in the 
division. In this way the entire uterus may be split down to and through 
the cervix, or, if preferred, each side may be cut through at the vagino- 
uterine junction, leaving the cervix as a simple stump. As the lower por- 
tion is drawn upward, the uterine artery becomes visible and is secured 
with clamp forceps. Further traction upon the mass rolls out the fibroid 
growths from the broad ligaments, and later renders visible the ovarian 
artery, which is also secured. The broad ligament is clamped external to 
the ovary and tube, and the mass removed. A similar course upon 
the opposite side leaves us with the uterine and ovarian vessels clamped 
ready for the application of the ligature. 

The remaining steps of the operation may be completed as described 
in the previous operative procedures 

12. Panhysterectomy, or total extirpation of the uterus, is the procedure 
of election in those cases in which the cervix has been taken up largely 
by the extension of the growth, or when it has been lacerated or is the seat 
of extensive disease. This operation may be performed by a number of 
methods: 

/. The Method of A. Martin, of Berlin. With the patient in the dorsal 



GENITAL TUMORS. 65 1 

position, the tumor is drawn out through a large median incision and, if 
necessary, made more movable by the enucleation of masses after the 
capsule has been split. The infundibulopelvic ligament is ligated and 
the broad ligament divided until the cervix is reached, beginning usually 
upon the left side, but in all cases on that in which the procedure would be 
most complicated. Having completed ligating one side before attacking 
the other, a pair of clamp forceps is applied on the uterine side of the line 
of ligature. The broad ligament is divided between the forceps and 
ligatures to the cervix. The uterus can then be brought over the sym- 
physis pubis, the posterior fornix is cut through by scissors, close to the 
cervix, and the two edges of the wound united by sutures. Sometimes 
bent forceps are passed, and from the vagina made to tear through the 
posterior fornix into Douglas' pouch, and, by separating the blades, 
the structures are torn with less danger of bleeding. A ligature is passed 
around the lower attachment of the broad ligament on the one side, which 
is then divided. The os is seized with a pair of forceps, which both closes 
the cer\dcal canal and draws the cervix upward and backward into the 
peritoneal cavity. The other side of the broad ligament can now be 
secured in a similar manner. The anterior vaginal fornix is divided, 
and the firmer bands of connective tissue one will meet in this situation. 
When these are cut through, the cervix separates easily from the bladder. 
Bleeding vessels are secured with the ends of the ligatures drawn down 
into the vagina. The peritoneum is united by transverse sutures over 
the vaginal w^ound, and the abdominal wound closed without drainage. 
II. The Method of Christopher Martin, of Birmingham. With the 
patient in the dorsal position, he delivers the tumor through a median 
incision and packs gauze pads above and below. A double thread is 
passed through the broad ligament at the junction of its upper and middle 
thirds, and midway between the uterus and pelvic wall. These two 
sutures do not interlock. By pulling them forcibly inward and outward, 
the punctured aperture is torn with a transverse slit and the two ligatures 
are tied as far apart as possible and the intervening broad ligament 
divided. The same process is repeated on the opposite side. He prefers, 
where possible, to leave one ovary and tube. The other is removed with 
the uterus. A second ligature is passed through the broad ligament 
about the level of the internal os and nearer to the uterus than the first 
one. The aperture puncture is again stretched, when the ligature is 
tied as far apart as possible and the intervening tissue divided. The 
bladder is then separated from the anterior surface. He also advises 
the use of the sound in the bladder, to define its upper edge. A curved 
incision, two-thirds of an inch from the upper edge of the bladder, is made 
from one broad ligament to the other, and the bladder is stripped down. 
The surgeon can determine when he has reached the vagina by following 
the tip of a pair of forceps pressed into the anterior fornix. The vagina 
is opened upon these with scissors and the opening enlarged. The poste- 
rior fornix is treated similarly. The ureters, when seen, are pressed out- 
ward. The uterine arteries now remain to be tied. Ligatures are passed 
through the remaining portion of the broad ligament, hugging close to 



652 



GYNECOLOGY. 



the mucous membrane of the lateral fornix of the vagina, and are 
tied upon either side. The uterus is cut loose, keeping the scissors 
as far as possible from the two lower sutures. The cut edges of the 
vaginal walls are drawn upward with forceps and carefully inspected. 
All blood-clots are sponged out of the pelvis and all bleeding points 
ligated. The ligatures may be cut short or may be left long and the ends 
used to draw the stumps into the vagina. The vaginal wound is not 
closed, but filled with a thick roll of iodoform gauze drawn through into 
the vagina. The abdomen is closed by interrupted silkworm-gut sutures. 
The gauze placed in the vagina is removed on the fifth or sixth day. 







_„.^.^«^^ 


. C\ 




'^ 


J \ L 'J 






^ 


• \\\ 


=: 


. 


















y^ 









Fig. 522, — Panhysterectomy. Doyen's method. The tumor rolled out, incision made from 
Douglas' pouch into the vagina upon the end of a pair of forceps. 

///. Doyen's Method. With the patient in the Trendelenburg 
posture, the tumor is lifted out through an abdominal incision and drawn 
forward over the pubes. A long, curved forceps, previously passed into 
the vagina, is made to project into Douglas' pouch, upon which an open- 
ing is made into the vaginal canal. (Fig. 522.) Through this opening 
the cervix is seized by the anterior lip, if possible^ and drawn upward 
and backward. While held in this position, the entire circumference of 
the attachment of the vagina to the cervix is under view and can be divided 
by scissors. (Fig. 523.) The cervix is separated from the bladder 



GENITAL TUMORS. 653 

by traction upward until the peritoneum above the bladder is reached. 
This is broken through and pushed back. The broad ligament external 
to the ovary and tube on the right side is clamped and incised with scissors. 
Clamp forceps are then applied to the broad ligament of the opposite 
side, when it likewise is cut through external to the ovary and tube. 
Frequently, by this method of procedure, the uterine arteries are not 
injured. The division is so close to the cervix that the main branch is 
not divided. Only the smaller branches are torn, and consequently 
do not bleed. The pedicles of the broad ligaments are ligated. The 



Fig. 523. — Cervix Separated from the Vagina and Being Pulled Away from the Bladder and 

Ureters. 

uterine arteries are also ligated and forceps removed. The vaginal 
mucous membrane can be united with the peritoneum by two or three 
sutures to prevent subsequent prolapse. The ends of the ligatures on 
the arteries are turned down into the vagina, and the pelvic peritoneum 
can be united by a purse-string suture across the pelvis, so as to invert 
the stump of the broad ligament below this structure. The abdominal 
wound is closed without drainage. Doyen, in his earlier operations, 
trusted to the angiotribe alone, but later applied a catgut ligature in the 
groove. The latter procedure is preferable. 

IV. Schauta'' s Method. The tumor and uterus are drawn out through 
a median incision and the broad ligament on each side divided between 
clamp forceps. The anterior peritoneum is divided and, with the 
bladder, stripped down to the vagina; the tissues are clamped upon each 
side and the vagina opened right and left between the clamps and the 
uterus. The tumor is now held by the anterior and posterior vaginal 



654 GYNECOLOGY. 

walls, which are secured by curved clamps, and the uterus removed. 
Ligatures are substituted for the clamps, which are left long and employed 
for vaginal drainage. The abdominal cavity is closed by union of the 
peritoneal folds over the vagina. 

V. Richelot, through an abdominal incision, first separates the anterior 
peritoneal fold and bladder. The uterine arteries are found, clamped 
by forceps, and cut close to the uterus. The anterior culdesac is found 
and opened; the cervix seized and drawn upward and forward. The 
cervix is separated from the vagina by a circular incision, and the broad 
ligaments are separated in sections from below upward. This plan 
affords an effective procedure when there are extensive adhesions follow- 
ing disease of the appendages. All the clamped vessels are securely 
ligated and the vaginal wound is closed with catgut. 

For some time I have pursued the following details in this operation : 
After cleansing the abdomen and vagina, a roll of gauze is packed firmly 
into the latter with its end projecting. Through a sufficiently long median 
abdominal incision, the tumor is secured by a myoma screw and drawn 
over the symphysis. Each broad ligament external to the tube and ovary 
and the round ligaments are clamped and cut between the clamps and 
the uterus. The uterine ends of the ligament are clamped when the vessels 
bleed. An incision is carried through the peritoneum in front from one side 
to the other and the bladder is pushed down. The tilting of the fundus 
uteri to the left renders prominent the right uterine artery, which is 
clamped and cut after which the vagina is opened and separated from the 
cervix by cutting around the latter with scissors. Traction on the cervix 
now makes visible the left uterine artery from below. This is clamped 
and the remaining portion of the ligament cut, separating the uterus con- 
taining the growths. The vessels are now ligated separately or in mass 
with chromic catgut. Generally three ligatures are required on each side, 
one for each artery of the round ligament, and the ovarian and uterine 
arteries. A suture on each side is passed through the posterior peritoneal 
flap, hugs close to the edge of the cut vagina and is brought out through 
the anterior peritoneal flap. The stump of the corresponding broad 
ligament is drawn down and the ends of this suture tied over it, thus 
affording additional security against hemorrhage from the ovarian artery. 
The intervening peritoneal flaps are united by continuous suture, making 
sure that the end of each stump is secured by it to avoid the danger of 
retraction. The abdominal wound is closed by carrying a needle armed 
with a chromic catgut suture through the aponeurosis, muscle and 
peritoneum of the right side of the upper angle of the wound, through 
the peritoneum only of the opposite side and thereafter through the 
peritoneal edge until the lower angle is reached when it is brought out 
through the muscle and aponeurosis. Silkworm-gut sutures are now 
passed about three-quarters of an inch apart through all the structures 
above the peritoneum and temporarily secured with clamp forceps when 
the catgut suture unites the edges of the aponeurosis by a continuous 
suture until the upper angle of the wound is reached where it is tied to 
the original end of the suture, thus replacing the deeper structures with a 



GENITAL TUMORS. 655 

single knot. The silkworm sutures are tied and the skin edges between 
them brought in apposition with plain catgut sutures. 

In difficult cases Bishop employs what he calls the combined method, 
which may be begun either below or from above. In the former with the 
patient placed in the lithotomy position, the uterus is exposed by retractors, 
seized, and drawn down with vulsellum forceps. The cervix is cleansed, 
packed with gauze, and if there is much discharge, the os is closed by a 
suture. A circular or ovoid incision is then carried around the cervix, 
completely dividing the vagina, when, with the finger hooked closely to 
the uterus, the bladder is separated from the anterior surface of the uterus 
and well to either side. In large tumors this cannot be accomplished to 
a great extent, but should be done sufficiently to expose the uterine 
vessels. Douglas' pouch is opened, and, with the one finger behind and 
the thumb in front, the uterine artery should be defined, ligated, and the 
ligament cut as far as the ligation extends. Hemorrhage is controlled 
carefully and the vagina packed loosely with gauze. The patient is 
then changed to the Trendelenburg posture and the abdomen opened 
through the rectus sheath of one side. All adhesions to omentum and 
intestine are separated, and ligatures applied where indicated. A 
gauze pad is placed over the intestine. When the ovaries and tubes 
are healthy, they are to be left. When diseased, part of the ovary at 
least is retained. One ligature is made to embrace the ovarian ligament, 
if the tube and the round ligament near the appendages are healthy 
enough to permit of their being retained, and is tied as near to the uterus 
as the retention of the ligature will permit. The ligament is cut close 
to the side of the uterus. The lateral incisions are joined by a curved 
incision anterior to the uterus, about half an inch above the line of the 
bladder, which is stripped down until the previous separation has been 
reached. The uterus is now attached only by the central portion of the 
broad ligament upon each side, which is ligated and the uterus cut away. 
Bleeding vessels are ligated and the ligatures cut short, the pelvis dried, 
a roll of gauze pulled through into the vagina, and the peritoneal flaps 
closed over it with a continuous catgut suture. All raw edges are care- 
fully inverted into the vagina, so that the peritoneal wound is perfectly 
smooth. Bishop closes the abdominal wound with catgut for the peri- 
toneum, crin de Florence for the aponeurosis, and horsehair for the skin. 
With the insertion of the last layer, the skin should be cleansed, dried, 
and painted with celluloidin, which forms an air-tight covering. 

Bouilly preferred to begin from above and finish from below. He 
delivers the tumor through the median abdominal incision with the 
patient in the Trendelenburg posture, divides the broad ligament between 
double ligatures, incises the peritoneum in front of the uterus, and 
pushes down the flap with the bladder, ligates the broad ligament so 
as to include the uterine arteries, amputates through the cervix, and 
closes the abdomen. Then, with the patient in the lithotomy position, 
he removes the cervix per vaginam, sutures the peritoneal flaps from 
below, and plugs the vagina with gauze. This procedure is particularly 
valuable in a sloughing fibroid which communicates with the vagina. 



656 GYNECOLOGY. 

Summary. Notwithstanding the recent able contributions to the 
literature of this subject, in which the writers advocate radical measures, 
I remain convinced that in the great majority of cases the aim of the 
surgeon should be to save and not sacrifice. A hysterectomy, partial 
or complete, should be his practice only when it is impossible to preserve 
a functionating uterus. In submucous growths, with hemorrhage as a 
marked factor, the tumor, when accessible, should be removed by torsion 
or excision of its pedicle. When the tumor is still within the cavity 
of the uterus, the cervix may be dilated with laminaria tents. If sufficient 
room is not secured thus the os can be split by a lateral or an anterior 
incision, as may be most convenient, and the tumor removed by torsion, 
by excision of its pedicle, or by enucleation. If the tumor is too large 
to permit of its ready extirpation, it should be removed by morcellation. 
Vaginal hysterectomy should be confined to uteri containing growths 
which are not too large to permit of their ready passage through the 
vagina, and yet in which the uterine structure is so taken up and involved 
as to preclude the retention of a healthy organ, or in which the ovaries 
and tubes are secondarily involved, making the retention of the uterus 
after the removal of the growths of no value. Of the various abdominal 
operations, myomectomy, enucleation of the growth, or partial or com- 
plete hysterectomy can be performed. The principle already enunciated, 
that no organ should be sacrificed whose function can be maintained, 
must govern as well in the abdominal as in the vaginal procedures, and 
when the ovaries and tubes are in a condition to justify the retention of 
the uterus, myomectomy or enucleation should be practised, even though 
a number of growths are present. 

The above was written five years ago, but candor obliges me to admit 
that several of the patients from whom I enucleated growths have had 
recurrence, particularly where a number of growths were removed. 
In the light of this experience, I believe it is better to do hysterectomy 
in a woman over thirty -five years of age whose uterus contains a number 
of growths. The objection to enucleation frequently advanced, that the 
cicatricial changes in the uterine wall which will result from the enucleation 
of a number of growths will unfit the organ for the exigencies of gestation, 
labor, and the puerperium, would seem to be valid and can be combated 
only in the line of experience. To contribute to this service I would 
relate the history of the following patient: A Japanese woman, aged 
thirty-three years, a patient of Dr. A. B. Shimer, of Atlantic City, was 
sent to me in February, 1903, because of an abdominal tumor. An 
irregular nodular mass was found in the median portion of the abdomen, 
projecting two inches above the symphysis and a little to the left. Care- 
ful physical examination made it manifest that it was a part of the uterus 
and that it filled up the pelvis. Hysterectomy was advised. She entered 
St. Joseph's Hospital the latter part of April, 1903, when the growths 
were exposed by abdominal incision. They were found so situated in the 
anterior and posterior walls of the uterus that enucleation seemed possible. 
The growths, thirteen in number, were enucleated, but without opening 
into the uterine cavity. The anterior wall of the uterus was much 



GENITAL TUMORS. 657 

mutilated, but was quilted together, producing a satisfactory looking 
organ. To prevent the uterus from falling back into the pelvis the fundus 
was secured to the abdominal wall by two turns of the continuous catgut 
suture closing the parietal peritoneum. She developed an infection of 
the abdominal wound from which considerable pus was discharged. 
Four weeks following the operation a slough was removed from the depths 
of the wound, which contained the catgut sutures employed to close the 
uterine wound, after which the recovery was rapid and the patient was 
discharged cured. A communication from Dr. Shimer, dated June 16, 
1906, informs me she was married on the fourteenth of October, 1903, 
and in November, 1904, gave birth to a healthy child weighing 
seven and one-half pounds. As the presentation was a vertex in an 
occipitoposterior position, the delivery was instrumental. Subsequent 
to her delivery her health was excellent. In a second labor she went 
into a collapse and died, with symptoms indicating possible uterine 
rupture and internal hemorrhage. A number of instances have been 
reported where examination has revealed unsuspected malignant degen- 
eration complicating the tumor; also reports of recurrence in the stump, 
the danger of which is lessened by panhysterectomy. Another disputed 
question is whether the ovaries shall be removed or one or both be 
retained. Those who advise the retention of an ovary claim that its 
preservation prevents the distressing symptoms associated with the 
premature menopause. I formerly practised the retention of ovarian 
stroma whenever possible, but such unused organs atrophy early, and 
the distressing phenomena become just as acute. Not infrequently will 
it be found necessary to reoperate because of neoplastic changes in the 
ovary. In many cases the changes in the tube and ovary already exist, 
making the removal of these organs desirable. When the uterine structure 
is greatly involved or when ovarian, uterine, or tubal disease complicates 
the condition, the operator may be forced to resort to either partial or 
complete hysterectomy. My experience inclines me to advise complete 
hysterectomy, for the retention of the cervix affords no special advantage. 
Its complete removal does not add to the difficulty nor prolong the opera- 
tion. It affords better drainage and expedites the recovery of the patient. 
In nearly all cases the clean removal of the uterus, ovaries, and tubes 
is more readily accomplished than is the retention of an ovary. No 
one operation can be made applicable to every patient. In the majority 
the method I have described on page 835 will prove the most satisfactory. 
A\Tien the broad ligaments are shortened by inflammation and the pelvis 
filled up by myomata, the operator may be unable to reach the cervix, 
or work down on either side, when, of course, another method of 
procedure must be chosen. The uterus containing the growths may be 
divided by vertical section, and through the culdesac portions of the 
tumor mass can be enucleated, thus decreasing the size of the structure 
and affording more room. Proceeding from below upward intraliga- 
mentary growths are shelled out with but little danger to the ureters, 
and better facility is afforded to secure hemostasis. Where access to 
one side of the pelvis is partially barred by inflammatory shortening or 
42 



658 GYNECOLOGY. 

the ligament is occupied by myomata, the Bishop modification of the 
Pxyor- Kelly operation permits ready removal of the uterus and growths. 

313. Accidents during Operation. Hemorrhage is an accident 
which is avoidable with careful application of ligatures. Where the tis- 
sues are ligated en masse, the angiotribe, by compression of the tissue, 
forms a groove in which the ligature may lie with less danger of its loosen- 
ing. Where the ligated mass is large and vessels are greatly distended, it 
is prudent to place a second ligature back of the first upon the more im- 
portant vessels. The compression furnishes a button over which the lig- 
ature is unlikely to slip. When the cervix is retained, bleeding from the 
stump is avoided by applying ligatures upon each side to control the 
blood-supply from the uterine arteries. One advantage of the entire 
removal of the uterus is that hemorrhage, when it occurs, is at once re- 
vealed by its discharge from the vagina. Internal hemorrhage will be 
indicated by symptoms of increasing shock, and the occurrence of such 
symptoms should be considered an indication for prompt reopening of the 
wound to secure the open vessel, for, should the patient rally from the 
hemorrhage, the large accumulation in contact with the intestine in the 
weak state of the patient adds to her subsequent danger from the pos- 
sibility of sepsis. All bleeding vessels should be secured firmly before the 
peritoneal wound is closed. Care must be exercised in short broad liga- 
ments that the ovarian artery is not retracted behind the peritoneum from 
the grasp of the ligature, there to produce a concealed hemorrhage or 
thrombus which may become so large as to open into the peritoneal cavity. 

In the injuries to the hollow viscera the bladder is most likely to be af- 
fected, as it is often drawn up by the growth and is closely attached to its 
anterior surface. Its relations to the uterus and tumor will depend largely 
upon the situation of the growth. A tumor which has originated in the 
lower part of the anterior wall of the uterus may readily drag up the blad- 
der and cause it to be displaced upward. The bladder may be displaced 
to one side, and not cover the anterior surface of the uterus and tumor. 
This may occur because of partial torsion of the neck of the uterus or 
from the size of the growth. In one case I accidentally incised the blad- 
der when opening the abdomen, as it was displaced upward and to the 
left side and formed a distinct tumor that did not disappear entirely 
after the employment of the catheter. The opening was sutured imme- 
diately, the bladder separated from the surface of the growth, and the re- 
covery of the patient was unretarded. Inflammatory adhesions may bind 
the bladder to the anterior surface of the tumor, and in the subsequent 
development may drag it so high that it is overlooked in the separation of 
adhesions. In such a way I was so unfortunate as to incise the fundus 
where adhesions were extensive, involving both anterior and posterior 
surfaces. In this patient recovery took place after the bladder wound was 
sutured. When the bladder is injured, the wound should be closed at 
once by sutures, whether it occurs upon the peritoneal or on the nonperi- 
toneal surface. In the use of the sutures precaution should be exercised 
that they do not enter the vesical mucous surface. It is well to have a 
double row of sutures, in order to bring a larger surface of bladder-wall 



GENITAL TUMORS. 659 

in apposition. In the subsequent convalescence the bladder should be 
frequently evacuated. A\Tien the wound has been extensive, it would be 
advisable to employ a permanent catheter for the first week, and for the 
second week to have the urine drawn at frequent intervals. The possible 
displacement of the bladder by the growth should always be considered, 
and care should be exercised to avoid its injury. 

Injuries of the Ureter. The situation of the ureter beside the cervix 
makes it particularly vulnerable in the removal of large fibroid growths, 
especially where the growth has developed low in the broad ligament. 
In some cases the growth shoves the ureter upward until we find it in a 
groove between the tumor and the uterus. In such patients the dissection 
should be practised most carefully in order to avoid injury to the ureter. 
The Doyen operation lessens the danger to both bladder and ureter; 
the cervix is pulled away alike from the bladder and the ureters. In the 
intraligamentary variety the tumor is dragged away from its relations to 
the ureter. In cases of injury, and particularly where the ureter has been 
cut, the proper course would be: 

1. To establish an anastomosis between the ends of the divided ureter. 
(Fig. 249.) The union can be end to end, the cut surfaces being made 
oblique. Another method is to split the vesical end and scrape the 
mucous surface and insert the renal end, securing it by sutures. 

2. Transplantation of the renal end into the bladder. (Fig. 248.) In 
introducing the ureter, it is important that it should be anchored in the 
bladder in such a way as to prevent it slipping back or drawing away from 
its attachment to the bladder surface, which would permit the urine to 
escape into the peritoneal ca^dty. If the union with the bladder is difficult, 
because the injury of the ureter is situated so high that the latter reaches 
the bladder only upon slight stretching, it is better to anchor the bladder 
to the side of the pelvis at a higher level, so that no traction shall be 
made upon the shortened ureter. When the ureter is too short to permit 
of an anastomosis with its vesical end or its transplantation into the blad- 
der, the following alternative procedures have been suggested. 

3. Carry the ureter across and anastomose it with the ureter on the 
opposite side. This procedure in my judgment is only mentioned in 
order to be condemned. The ureter if long enough to permit this, should 
be introduced into the bladder. I should hesitate about imperiling the 
patient by disturbing the remaining conduit. 

4. The introduction of the ureter into the corresponding colon. This 
operation has not been attended with very satisfactory results. The 
infection and gases from the intestine have been known to be carried 
through the ureter to the pelvis of the kidney, producing fatal inflamma- 
tion. The contact of the urine with the intestine will cause considerable 
irritation and produce a marked diarrhea. 

5. Bring the extremity of the ureter out through the abdominal 
wound or make a fistulous opening upon the skin surface. The preferable 
position for the opening is through the triangle of Petit in the loin. A 
fistula on the anterior abdomen is attended with no little discomfort to the 
patient, as the constant soiling of her person and clothing with urine is 



66o GYENCOLOGY. 

distressing to a cleanly patient and annoying to those who have to be 
associated with her. The lumbar fistula, however, permits the urine to be 
collected without such discomfort. Probably still better is a nephrostomy 
by which the urine can be collected directly from the pelvis of the kidney. 
Watson, of Boston, has recounted cases who have lived comfortably for 
years with both kidneys drained thus. 

6. Ligate the ureter and drop it back. This ligation should be made 
by a double ligature, for the reason that, under the process of pressure- 
atrophy, the ligature becomes loosened and, when single ligatures are 
used, the urine escapes into the peritoneal cavity and causes urinary 
infiltration and septic peritonitis. This condition is less likely to occur 
when a second ligature is applied from half an inch to an inch above 
the first. The urine continues to be secreted until the pressure within 
the cavity of the kidney is equal to the blood pressure, when the secre- 
tion is arrested. In such cases the kidney, unable longer to secrete the 
urine, becomes a useless organ and atrophies, while the extra work is 
taken up by the remaining kidney. The result of the procedure, of 
course, will depend, as it would in nephrectomy, upon the condition of 
the remaining kidney. 

7. Removal of the kidney. 

Injuries of the intestine are less frequent. They may occur as a result 
of extension and firm adhesions to the surface of the growth. The injury 
is more apt to be found in the sigmoid flexure of the descending colon 
and the rectum. As a result of chronic inflammation, the adhesions 
may be extensive and firm, and lead to injury of the intestine before 
the possibility could be suspected. I operated on a patient who had 
carried a fibroid as large as a pregnancy at term, for eighteen years. 
When I opened the abdomen the small intestines were firmly adherent 
over the tumor to such an extent as to forbid either their dissection from 
it or resection of the intestine. I split open the tumor and trimmed out 
its inside, then sutured together the shell with the intestine attached. 
The patient had an uninterrupted convalescence. In all cases of exten- 
sive adhesions, after the removal of the growth careful examination should 
be made to ascertain the existence of intestinal injury. Such adhesions 
may also result from complications incident to suppurative disease of 
the tubes associated with the growth. Very frequently an opening will 
occur between a tubal abscess and a knuckle of intestine through which 
the contents of the abscess have been partially drained. During an 
operation for the removal of a fibroid growth associated with pelvic 
suppuration I found an opening from a left tubo-ovarian sac into the 
anterior surface of the sigmoid, through which the thumb could be 
introduced. This sinus had served to empty the abscess at frequent 
intervals. In closing an intestinal opening its edges should be trimmed 
carefully and thus remove tissue of low vitality or such as has been in- 
jured during the procedure, and secure contact of the surfaces by a double 
row of sutures. Continuous chromic catgut suture is a very serviceable 
material, but, as has been previously mentioned, the suture should be so 
introduced as to hold extensive surfaces in apposition. The patient 



GENITAL TUMORS. 66 1 

should be kept subsequently upon an albuminous broth diet, and early 
evacuation of the bowels should be accomplished, affording no opportunity 
for hard fecal masses to form in this portion of the intestine. In these in- 
flammatory fistulous cases gauze packing drainage is advisable generally, 
for it is always difficult to make certain that all tissue' of low vitality has 
been excised and that a fistulous opening may not recur. When the abdo- 
minal wound is closed, leakage may cause fatal infection of the peritoneal 
cavity before the gravity of the condition is recognized. If a small 
fistulous opening follows in such a case, it is preferable to keep the wound 
open and the cavity cleansed thoroughly by frequent irrigation both by 
the rectum and the abdominal wound, and to permit nature an opportunity 
to close the opening by granulation. Nature soon shuts off the tract of 
the general peritoneum and prevents the possibility of its infection. 
To reopen such a wound in order to close the fistula increases the danger 
of general infection. Where the caliber of the intestine is free and 
unobstructed, a fistula will close by granulation, but should the intestine- 
be obstructed or kinked below the fistula, the latter will not close. The 
effect of a fistula will depend upon its size and position in the intestinal 
tract. Free discharge from the intestine high up means that much 
nutritive fluid is removed from the processes of absorption. Therefore- 
a corresponding loss of vitality results. A fistula in the large bowelH 
may exert but little influence upon the general nutrition. 

314. Causes of Death Following Hysterectomy. The most 
frequent causes of fatal results are: shock, hemorrhage, and septicemia. 
Shock is a vasomotor disturbance which may result from -severe hemor- 
rhage during or preceding the operation. It is especially prone to occur 
in individuals in whom the percentage of hemoglobin is small. It is pro- 
moted by prolonged operations, injudicious administration of anesthetic, 
exposure of the viscera to cold, or drying in the atmosphere. It is more 
likely to occur in the neurasthenic and poorly nourished, in \ictims 
of tuberculosis, or in patients who have been suffering from prolonged 
inflammatory complications. In fibroid growths complicated by dense 
inflammatory adhesions the traction upon important sympathetic ganglia 
in breaking up adhesions may be attended by fatal shock. Hemorrhage 
may be the cause of death during or shortly following an operation, 
from rupture of a large artery or vein, or from failure to control bleeding 
during the procedure. These occurrences should be rare, as the opera- 
tor and his assistant should be alert to secure vessels before they are 
injured or upon the first spurt when the vessel is severed or torn. A fatal 
hemorrhage may result from retraction of an important vessel or from 
slipping and loosening of an insecurely placed or tied ligature. This 
is more likely to occur when the pedicle is short and thick and is tied en 
masse. Unless the gravity of the condition is appreciated at once, the 
hemorrhage may be fatal rapidly. If the enfeebled condition of the 
patient leads to the formation of a clot and arrest of bleeding, the large 
accumulation of blood in the peritoneal cavity may stfll be a source of 
danger to the patient through its infection by its contact with the intestine 
or from pathogenic germs which may have been left in the abdominal 



662 GYNECOLOGY. 

cavity. In this sense it may furnish the cause for the subsequent death 
of the patient from septicemia. The danger from septicemia is greatly 
enhanced where the operation has been difficult, due to intraligamentary 
growths; when the. operation has been complicated by extensive adhesions, 
suppurative processes in the tubes, and hematoma of the ovaries. Less 
frequent but none the less to be regarded as causes are pneumonia, pul- 
monary embolism, ileus, tetanus, and secondary manifestations of sepsis, 
as phlebitis. (For after-treatment see Sections 150-164.) 

PUERPERAL TUMORS. 

315. Physometra, an unusual form of enlargement of the uterus, 
giving the appearance of a tumor, is an accumulation of gas in the in- 
terior of the uterine cavity. This affection may be produced during 
the puerperium or without it. After the woman is delivered the 
uterus is large and air will enter it. If expulsion is delayed by ineffec- 
tive contraction of the organ, in the course of convalescence the pla- 
cental fragments or retained portions of membrane undergo decomposi- 
tion and produce a putrid gas, which, by larger accumulations in the 
organ, produces the condition known as physometra. It may develop 
in the nonpuerperal uterus, as is well indicated in the following patient, 
as cited by Auvard: A negress, forty-six years of age, reached the meno- 
pause and presented considerable abdominal enlargement. Her periods 
had not been seen for three months. According to her calculation, she 
was certainly pregnant. The term had passed four months. She called 
a physician and arranged that he should attend her in labor. Under an 
attentive examination of the patient to determine the cause of the uterine 
enlargement a sound was introduced into the cavity of the uterus, when, 
in less than a minute's time, an offensive gas was driven out with great 
impetuosity. After this evacuation the uterus returned to its normal 
proportions and the patient recovered. In the acceptance of this condi- 
tion we must admit the possibility of the secretion of gas in the uterine 
cavity, or the putrefaction of retained intra-uterine debris after the oc- 
clusion of the cervical canal. Decomposition of the debris results in the 
formation of gas and the distention of the organ. The treatment consists 
in the establishment of the permeability of the canal. 

316. Hydrometra is due to any cause by which the internal orifice 
of the uterus becomes closed and the secretion retained in a woman 
who suffers from amenorrhea or in one suffering from endometritis after 
the climacteric has occurred. It practically produces a mucometra, or, 
when the liquid is serous and clear, it is denominated hydrometra — a term 
which includes all seromucous uterine collections. If the endometritis 
is purulent, we have a pyometra. Hydrometra is exceedingly rare. 

317. Hematometra is an accumulation of blood in the interior of 
the uterus, and has been described under malformations. 

318. Pyometra. Pyometra is an accumulation of pus in the uterus, 
and is more likely to be found in women some years after the climacteric. 

319. Hydatid cysts of the uterus is, however, a condition free 



PUERPERAL TUMORS. 



663 



from the presence of hydatids. There are a large number of cysts, 
which form in the mucous membrane of the uterine cavity-^generally 
following labor or abortion, and known as cystic mole. The condition 
is so closely associated with that known as deciduoma malignum that its 
consideration will be postponed until the discussion of the latter disease. 
320. Mucous polypi of the uterus are growths which arise from 
the uterine mucous membrane, and are distinct from the fibroid polypi, 
with which they are often confounded. (Fig. 521.) The latter arise 
from the muscular wall and push the mucous membrane before them. 



1 


r 


w 




t • 


J 




IjB* '"^^^B 




1 


IW 


^■T'^Br-' "'^^B 



Fig. 521 — Mucous Polypi. 

The former result from hypertrophy of the glandular structure of a 
limited portion of the uterus, which causes them to push out and form a 
polypoid growth. A number of these may occur within the cavity of 
the uterus and interfere with the performance of its functions. They 
are associated with endometritis. They are due to a localized in- 
flammation and hypertrophy of the glandular tissue. These growths 
may vary from the size of a filbert or less to a growth consisting of a grape- 
like cluster of glands attaining the size of a small orange, which is extruded 
from the cervix and hangs by a pedicle from the uterine cavity. They 



664 GYNECOLOGY. 

may occur upon any part of the mucous membrane; frequently they arise 
from the cervix and protrude from the os in small masses. The treatment 
is the same as that of the inflammation with which they are associated: 
thorough curetment of the uterus; removal of the growths; disinfection 
and sterilization of the uterine canal, and gauze packing to promote 
subsequent drainage. The operation should not be devoted to the re- 
moval of the growths only, as the cervical canal is likely to become 
irritated and cause subsequent pelvic inflammation. 

Another form of uterine tumor is placental polypus, which consists of a 
mass of coagulated blood, in association with a portion of the placenta 
or the decidua. It hangs by a pedicle from the uterine cavity and acts 
as a source of irritation until its removal. The mass becomes compressed 
in the uterine cavity and forms a firm growth, which subsequently may 
become partly organized, or, under the influence of insufiicient nutrition, 
may become decomposed, and cause putrid intoxication. Treatment 
will consist in the thorough removal of the growth. This can be done 
with the finger or by the introduction of forceps, which seize and twist 
off the tumor. 

321. Malignant tumors, as seen by our classification, originate in 
embryonic tissue and are divided, according to their origin, into two 
classes: the epithelial and the connective tissue. They differ from the 
benign tumors in having no limit to their growth and extension. A 
malignant tumor is one which destroys the organ in which it originates 
and penetrates to the surrounding structures without respecting the 
barriers which nature may erect against its growth. There is no tissue 
of the body which can offer effective resistance to its encroachment. 
Malignant growths are further characterized by a tendency to extend 
themselves to remote tissues and organs by transmission through the 
lymph- and blood-vessels. Loosened pieces of tissue are washed away 
from their original source to new locations, thus affording development 
to new foci of a structure similar to that from which they originated. 
A further characteristic is that they exhibit a disposition to recur after 
removal. The demarcation between malignant and benign tumors is 
difficult to fix. Thus, papillary ovarian cysts may rupture and subse- 
quently implant themselves upon and infect the general peritoneal cavity. 
Syphilis and tuberculosis manifest an inclination to extend to the sur- 
rounding structures and to be reimplanted through the blood-vessels. 
But the manifestations of syphilis and tuberculosis are capable of modi- 
fication, of arrest, and even cure. The papillary infection generally 
undergoes atrophy and disappears when the original source of infection 
has been removed. 

Pathologic classification of malignant disease of the uterus can be 
arranged as in other organs of the genital tract, in tumors springing from 
the embryonal epithelial cells, of which there are two varieties, namely: 
carcinomata and chorio-epitheliomata, and from the embryonal connec- 
tive-tissue tumors, of which there are also two varieties of malignant dis- 
ease, namely: sarcomata and endotheliomata. Carcinomata may develop 
from any portion of the uterine mucous membrane between cervix 



PUERPERAL TUMORS. 665 

and fundus, and in either from the surface epithelium or that lining the 
glands. Chorio-epithelioma develops in the second layer of cells, known 
as Langhans' cells, covering the chorionic villi. Sarcoma may originate 
in the connective tissue of the endometrium or in the tissue of the mural 
portion of the organ. Endothelioma develops from the endothelial cells 
of the lymph-vessels, blood-vessels, and the serous covering of the uterus. 
Furthermore, as a rule, it has no alveolar structure. 

Anatomic Classification of Carcinoma. Carcinoma may arise from 
any portion of the mucous membrane lining the uterus or that covering 
the cervix external to the os, the latter being the portion denominated 
by the Germans the portio vaginalis. According to the anatomical 
location, carcinoma is classified as: i. Carcinoma of the vaginal portion of 
the cervix, that portion between the external os and the vaginal vault; 
2, carcinoma of the cervical canal, which is bounded below by the ex- 
ternal OS and above by the internal; and, 3, carcinoma of the corporeal 
mucous membrane, whose inferior boundary is the internal os. Car- 
cinomata are further divided histologically into squamous-cell carcinoma 
and cylindric-cell carcinoma or adenocarcinoma. Squamous-cell car- 
cinoma is the form of disease found in the epithelial covering of the 
vaginal portion of the cervix. In rare instances it has been found in the 
endometrium of the uterine body, and its origin explained by the pres- 
ence of parasitic epithelial cells; but later investigations demonstrate 
that it more probably had followed metaplasia of the surface epithelium 
from long continued irritations. Cylindric-cell cancer develops from 
the epithelial covering of the mucous membrane, but with greater prob- 
ability from the epithelial cells lining the glands of the cervix and 
also in the tubular glands of the uterine body. Of the different ana- 
tomic varieties, the squamous-cell-carcinoma of the portio vaginalis is 
the most frequent. Next in order of frequency is the cylindric-cell 
cancer of the cervical canal, while the least frequent is the cylindric-cell 
cancer of the uterine cavity. Carcinoma of the uterus ranks in frequency 
next to cancer of the stomach. In 31,482 cases of carcinoma Welch 
found 29.5 per cent, were of the uterus. Williams estimates that 
death from cancer in women over thirty-five years of age is one in 
thirty-five. In a survey made by Dr. P. B. Bland of the vital statistics 
of the city of Philadelphia extending over a period of twenty-five years, 
from 1878 to 1903, 9777 women were found to have died from cancer. 
Of this number, 3172 were attributed to cancer of the uterus, 2139 to 
cancer of the stomach, and 1776 to cancer of the breast. During this 
period 1980 men died of gastric cancer, making a total from cancer of 
the stomach in males and females of 41 19. These statistics demonstrate 
that cancer of the uterus is by far the most common form of malignant 
disease, and account for the fact that twice as many women as men die 
from cancer. The squamous-cell form carcinoma is by far the most 
frequent malignant disease of the uterus — more frequent, indeed, than 
adenocarcinoma of the cylindric form of disease in both the cervix and 
body. The squamous-cell variety develops from the atypical prolifera- 
tion of the squamous epithelium covering the vaginal portion of the 



666 



GYNECOLOGY. 



cervix. In women who have borne children and in whom repeated 
lacerations of the cervix have occurred, metaplastic changes in the epi- 
thelium may lead to an extension of multiple-layered epithelium some 
distance into the cervical canal or even into the body of the uterus. 
This explains the occasional existence of apparent squamous-cell-car- 
cinoma within the cervical canal and body, and accounts for the mixed 
forms frequently present. 

322. Development of Squamous-cell Carcinoma. This form of 
malignant disease may develop on the anterior or posterior lip of the cer- 
vix or frequently on the site of an old laceration. Cullen distinguishes 
three stages, according to the degree of infiltration and disintegration of 
the part affected: 

I. A rapid proliferation of the squamous epithelial cells. The lesion 
appears first as small, papilla-like nodules, hard at the base, more or less 
friable on the free surface, which bleed easily on examination. They 




Fig. 522. — Squamous-cell Carcinoma of Cervix. 
a, Cervical canal; b, portion of vaginal wall involved in the malignant process. 



present a glistening, bluish- white appearance on the surface, and on section 
two zones are recognized — the first or peripheral is composed of a more 
or less friable, brain-like consistence and of a yellowish-gray, brain color. 
The second or basal zone lies in juxtaposition to the cervical tissue, is 
of a yellowish-white color, and of a dense, cartilaginous consistence. 
Close inspection of these nodules reveals fibrous striations or trabeculae 
occurring throughout their tissues. These bands surround or isolate nests 
of friable homogeneous tissue, the so-called cancer assemblages or cancer 
nests. These areas may be emptied of their contents by compressing 
the tissue, and small shallow depressions remain. It is important that 
such areas be not confounded with dilated cervical glands containing 
inspissated mucus — the so-called Nabothian cysts. The small papillary 
projections or processes manifest in the nodules grow and spread rapidly, 
forming a large cauliflower-like mass. Such a neoplasm has been des- 
ignated the cauliflower cancer. In this stage the disease may be so 
extensive as to fill the entire vaginal vault. The extension of the papillary 
process into the vaginal wall appears a determination of the malignant 
disease to follow nature's law and travel in the line of least resistance. 



PUERPERAL TUMORS. 667 

While this external proliferation occurs, there is a simultaneous invasion 
and consequent involvement of the subjacent tissue, which becomes 
dense, hard, and indurated. Section of this nodule reveals the neoplasm 
appearing as a hard, cartilaginous, yellowish-white growth extending 
upward toward the internal os, and outward toward the vaginal vault, 
and later, also, in the direction of the parametrial tissue. Such neoplasms, 
when closely inspected, disclose glistening trabeculse of fibrous tissue, 
constituting the stroma, which form the walls or spaces in which assemble 
the parasitic epithelial cells. Thin sections made from such an area 
when compressed and washed out present a sieve-like structure. It is 
unfortunate that squamous-cell epithelium in this stage so frequently is 
undiscovered. It is rare, indeed, and usually only by accident, that the 
disease is recognized in this formative stage, for it is then wholly devoid 
of symptoms. It is self-evident that radical treatment in this stage would 
afford better results than are now obtained, because the disease then 
rarely has been projected beyond the uterus. 

2. A stage of moderate disintegration, of decided symptoms, and a 
period when the disease most frequently comes under operation. The 
palpating finger at this period will discover partial or total destruction 
of the cervix, and substituted therefor an irregular, cauliflower, fungating 
mass of tissue of a grayish-yellow color, friable and brain-like in con- 
sistence. The tissue breaks down under manipulation and bleeds 
freely. Instead of the cauliflower mass, which may have disappeared 
by sloughing, a large, irregular, crater-like ulcer exists, the floor and sides 
of which are irregular, hard, and covered with a sloughing, gangrenous 
tissue. The disease will be recognized as having invaded the structures 
beyond the cervix, and the latter organ may have been to a great degree 
destroyed. After the removal of the uterus, the base of such an ulcer 
appears to be composed of a yellowish- white, hard, cartilage-like tissue. 
This tissue ramifies the structure of the cervix by finger-like projections, 
as in the cauliflower growth. The disease extends, involving the vaginal 
vault and connective tissue of the broad ligaments. 

3. The final stage is characterized by extensive or complete disintegra- 
tion of the cervix and involvement of the circumjacent structures. Cancer 
in this stage is usually recognized from the history and physical symptoms 
alone, without a vaginal examination. Palpation reveals an entire destruc- 
tion of the cervix, and at its site a cone-shaped, sloughing, crater-like 
cavity. This has been described by some as resembling the cavity of a 
decayed molar tooth, its walls and floor covered with necrotic tissue. 
In palpation the tissue feels hard, granular, and presents numerous 
elevated nodules due to the presence of these finger-like processes. The 
disease reaches first that portion of the vaginal wall most contiguous to 
the original nodules. Generally the sides are first involved, then the an- 
terior, and lastly the posterior, wall. With the invasion of the parametrium 
the broad ligament becomes hard and dense, the bladder adheres to the 
uterus and the wall is infiltrated. The ureters are frequently surrounded 
by masses of this infiltration, and finally become involved therein. Fistu- 
lous communications may follow between the vagina and bladder and 



668 GYNECOLOGY. 

rectum. The disease may extend upward into the cervical canal as well 
as outward, but this course is less frequent. 

Histology of Squamous-cell Carcinoma. The histologic picture of 
cancer depends upon the stage at which it is subjected to microscopic 
study. In primary proliferation and induration prior to disintegration, 
several characteristic elemental changes are observed. The tissue secured 
for study should be so excised as to secure both healthy and diseased 
tissue, and the sections made therefrom should include both. The 
section of this tissue near the margin of the growth appears under the 
microscope similar to tissue showing a reactionary inflammatory change. 
Small round-cell infiltration and polynuclear leucocytes are present. 
As the edge of the neoplasm is approached, disturbances will be noted 
in the squamous epithelium. These occur in the form of piling up or 
proliferation outward of the cells. Occasionally a superficial loss will 
be seen, but always is seen an ingrowth or dipping down of the cells in 
cone-like processes into the cervical tissue. The mucous covering of the 
cervix, as a rule, remains intact until the growth is well advanced. Inva- 
sion of the parasitic cells is not limited to a single line of the stratified 
squamous epithelium, but all layers take part in the process and the nor- 
mal basal layer of large cuboidal cells forms the boundary of the advan- 
cing column. Should the section extend through one of the finger-like 
processes, these cuboidal cells will form the outer zone. External to the 
line of cuboidal cells are finger-like projections surrounded by a network 
of fibrous tissue, which contains some muscle-fibers and is known as the 
stroma. Areas of keratinization or hardening of the central portion or 
even of nearly all of the epithelial nests is seen. These areas are the 
so-called epithelial pearls, which are of a yellowish color and disposed in 
layers resembling an onion. Epithelial pearls, however, are less 
numerous in the squamous-cell epithelioma of the cervix than in the same 
form of cancer in other tissues of the body. This difference is incident 
to the fact that one layer of epithelium in the cervix is not so well developed 
and often is entirely absent. Active nuclear division in the parasitic cells 
is especially prominent. One characteristic of these wandering cells is 
the increased amount of coloring-matter (chromatin) they contain. Cul- 
len asserts that the pathologic diagnosis can be determined by the added 
color contents and the increased size of the cells. The cells vary in size, 
but are generally somewhat enlarged. The fibrous stroma enveloping 
the assemblage of cells (the cell-nests) is composed largely of fibrous 
tissue, yet contains a few muscular fibres and springs from the normal 
cervical tissue. This stroma, to a varying degree is invaded by round-cell 
infiltration, which is most marked in the margins of the growth and is due 
to the irritation of the invading neoplasm upon the circumjacent tissues. 
This inflammatory cell infiltration about the growth is apparently the 
effort of nature to construct barriers against the invading hostile cells. 
Round-cell infiltration is especially marked in cases where the develop- 
ment of the neoplasm is slow, while it is slight where the growth is rap'd. 
In the latter, nature is overwhelmed by the rapid invasion and is unable 
to erect defensive barriers. In the stroma are situated the blood-vessels, 



PUERPERAL TUMORS. 669 

lymphatics, and nerves. The stroma varies in amount according to the 
rapidity of the growth. In tumors of rapid growth it is more frequently 
indefinite, the tumor being largely cellular. Rapidly developing malig- 
nant tumors grow in two directions: i, as an ingrowth and invasion of the 
cervical tissue proper; 2, as an outshoot or outgrowth of both stroma 
and cells, forming the cauliflower mass. 

Later, in moderate disintegration, cancer appears under the micro- 
scope to invade the tissue more extensively, but the margin of the growth 
shows the histologic picture seen earlier. The older portion of the tumor 
exhibits the changes incident to necrosis and is covered with broken- 
down tissue, blood and detritus, welded together by fibrin. The tissue 
immediately subjacent discloses more or less degenerative change. 
As the disease progresses hyaline degeneration occurs in both the proto- 
plasm and nuclei and occasionally giant cells will be found. As the can- 
cer advances the necrosis and disintegration changes are more marked. 
The cell-nests disintegrate frequently and contain necrotic tissue and pus. 

323. Adenocarcinoma of the Cervix. Cylindric-cell cancer, 
or adenocarcinoma of the cervix generally develops in the glands of the 
mucous membrane lining the cervical canal between the internal and the 
external os. The question has been disputed whether cervical cancer orig- 
inates in the cover epithelium or in the gland. Some assert that it arises 
from the free surface epithelium; others that it has its origin from 
the epithelium of the gland. Winter declares that the disease most 
frequently develops from the combined point of origin of the glandular and 
surface epithelium, but now it is accepted generally that this form of 
malignant disease may originate in either of these structures. The 
disease is manifest in a number of forms — sometimes as a rounded nodule 
involving almost the entire cervix before disintegration results. It may 
appear in the lumen of the cer^dcal canal in the form of tubercles, nodules, 
or papillary growths which fill up the cavity or are extruded from the os, 
while the external surface of the cervix is scarcely involved. Quite 
frequently the entire cervical canal is taken up with the cancerous process 
and yet pathologic changes are not manifest external to the os. The 
growth often appears as a hard, firm, waxy mass. Occasionally extensive 
inflammation of the diseased mucous membrane as well as of the muscle 
and cervical wall follows, causing thickening and hardening of the entire 
cervix. The carcinomatous nodule or nodules gradually undergo necro- 
sis, leaving a sloughing, crater-like cavity in place of the cervical canal. 
The disease confined to the upper part of the cervical canal, may remain 
totally unsuspected, because it is hidden behind an uninvolved external os. 
As the disease progresses it gradually extends downward and makes its 
appearance at the external os, but more frequently has broken through the 
cervical wall into the parametrium. The growth may be far advanced 
before the vaginal portion of the cervix exhibits any indication of its ex- 
istence. Palpation during this stage discloses the organ as hard, gritty, 
and nodular. Occasionally a fungus-like mass projects from the external 
OS. A section through the cervix may disclose an advanced stage and a 
condition resembling a worm-eaten cavity. The disintegration of the 



670 GYNECOLOGY. 

carcinomatous tissue causes extensive excavation, which enlarges the 
external os in a fissure of considerable breadth. A large portion of the 
cervical canal may disintegrate thus. The history of its progress indi- 
cates that adenocarcinoma differs essentially from carcinoma of the portio 
vaginalis. Invasion in the latter is superficial. Ulceration follows 
early, but in the cylindric-cell cancer of the cervix the invasion penetrates 
rapidly the parametrial connective tissue, while the vaginal portion of the 
cervix is involved late, if at all. Extensive invasion and disintegration 
of the cervical canal occur without any break in the continuity or any ap- 
pearance of the squamous epithelial covering the portio vaginalis. Con- 
sidering the changes which the cervix undergoes as a result of extensive 
glandular inflammation, with penetration of the whole cervical wall by 
obstructed glands undergoing cystic degeneration, it is evident how rap- 
idly the malignant growth would penetrate to the parametrial structures 
before manifesting its presence in the vagina. Cancer occasionally 
extends downward to the vaginal walls, but usually toward the body of 
the uterus and outward into the parametrial tissue. Occasionally it 
passes through the internal os and involves the mucous membrane of the 
uterine body. The entire uterine endometrium, or only a small portion 
of it may be invaded thus. Isolated cancer nests may occur in metastasis. 
The peritoneum may be penetrated, but the vesicocervical septum is 
more frequently invaded, affecting the bladder and enveloping the ureters 
with infiltration. The ureter is probably more frequently involved than 
the bladder, for in attempting complete removal of cancer I have 
often been compelled to excise portions of one or both ureters. The 
infiltration about the ureters obstructs the flow of urine and dilates the 
ureter and pelvis of the kidney, produces hydronephrosis, and when as- 
sociated with infection, pyonephrosis. Infiltration and subsequent disin- 
tegration and ulceration of the structures of the bladder and ureters, or 
that of the rectum may cause fistulous communications through which the 
contents of the bladder and the rectum enter the vagina. While adenocar- 
cinoma of the cervix does not invade the posterior wall and its investing 
peritoneum frequently, this occurs oftener than it does in cancer of the 
portio vaginalis. Extensive peritonitis is infrequent, as the invasion of 
the disease is preceded by inflammatory barriers. Occasionally, however, 
perforation may result and a suppurative peritonitis follow. 

Histology of Adenocarcinoma. The term adenocarcinoma will imply 
that the structure is of a glandular character. The disease develops 
generally in the glandular epithelium, although sometimes it may originate 
in the cover epithelium. The epithelium lining the glands proliferates, 
thus projecting into and filling up the lumen of the gland as small pro- 
cesses. These projections unite with one another and in this manner 
one gland may be subdivided into fifteen or twenty smaller glands. The 
epithelial cells lining the glands are tall, columnar, narrow, and some- 
what irregular in size. The cell nuclei are generally located at the base 
of the cell, but occasionally are found near the center. When a tendency 
of the cells to form new glands exists, the epithelial cells will be seen piled 
upon each other. It is often difficult, according to Waldeyer, to trace the 



PUERPERAL TUMORS. 67 1 

connection of the carcinomatous growth with the orifice of the gland, yet 
he has secured sections demonstrating it. Ruge and Veit have shown 
that the glandular epithelium which ordinarily consists of but one layer 
becomes several layers thick, and that the original arrangement of the 
epithelium is lost. This feature of the disease is always evident, and the 
parasitic cells, when compared with cells lining the normal glands, will be 
seen to have special characteristics of their own. The first tendency to 
proliferation is intraglandular, the cells pile over each other, forming 
several layers in which intraglandular outshoots are projected, dividing 
the original gland into numerous compartments. Extraglandular pro- 
liferation occurs later. The basement membrane is fractured, followed 
by a wide proliferation and projection of the epithelial cells into the inter- 
glandular fibrous stroma. The interglandular proliferation may be so 
extensive as to fill the gland lumen completely. Cross-sections of such 
occluded glands under the microscope resemble epithelial nests found in 
squamous-cell carcinoma. The papillary projections from the external 
OS are composed of papillae covered with one or more layers of cylindric 
epithelium. The stroma structure supporting these processes is more 
fully developed than that of the squamous-cell carcinoma. Generally 
the epithelial cells of adenocarcinoma of the cervix differ morphologically 
and decidedly from those seen in the cervical epithelium. Active nuclear 
division is always well marked. The stroma has its origin in the cervical 
tissue and is usually infiltrated with small round cells. Inflammatory 
infiltration in adenocarcinoma is not so marked as when this process 
occurs in the squamous-cell epithelioma. The more rapid development 
of the latter may explain the lessened amount. As the tumor develops, 
interference with its nutrition follows and this leads to necrosis and slough- 
ing. The older portion of the tumor, therefore, often is covered with 
disintegrated tissue, and immediately beneath it marked necrosis will be 
seen for a considerable depth. 

324. Adenocarcinoma in the body of the uterus has its origin in 
the mucous membrane lining the interior of the uterine cavity, and arises 
either from the surface of the epithelium or from the epithelial lining of 
the tubular glands. This is the rarest form of epithelial malignant disease 
of the uterus, and is more likely to occur in women later in life or in those 
who have not borne children. As it more frequently occurs in women 
following the climacteric, it is the most hopeful of the different varieties 
of uterine carcinoma. The disease may originate at any point in the 
uterine cavity from the internal os to the fundus. It is unusual for the 
neoplasm to extend toward the internal os, and rarely does it reach the 
external. Therefore, in making a positive diagnosis it is necessary that 
the uterine cavity should be dilated to permit of its exploration with the 
finger, or the curet should be used and the scrapings examined micro- 
scopically. The disease may begin as a circumscribed nodule, spring- 
ing from the surface of the mucous membrane, which consists of several 
delicate papilla-like processes. These processes may be irregular and 
wart-like in appearance, and the surface of the growth appears perfectly 
smooth. This is particularly true in the early stage of the development, 



672 



GYNECOLOGY. 



and the disease at this period may appear simply as a localized hyper- 
trophy of the endometrium. The nodule gradually increases in size, 
and about its base, as the disease progresses, several smaller nodules 
will be found. Occasionally it may appear simply as a polypus with a 
very small pedicle. This growth may be so large as to fill up the en- 
tire uterine cavity. Such a growth may not be unlike the benign mucous 
polypus and consequently be confused with it. It is usually, how- 
ever, more fragile and its surface less smooth. The proliferating 
mass is also much larger in comparison with the size of its pedicle. It is 
probable that these malignant polypi develop from the infiltration of 
distended uterine glands, or they may be produced by the malignant 
transformation of a benign mucous polypus. Epithelial malignant dis- 
ease of the endometrium generally begins as a localized growth, although 




Fig. 523, — Squamous-cell Epithelioma of the Uterus. 
a. Keratinization of cells forming epithelial pearls, h. Connective-tissue matrix, c. Collec- 
tion of atypical cells. 



occasionally the lesion, even in its earliest stages, simultaneously involves 
the entire mucous membrane. As it progresses, outshoots or finger-like 
projections are produced, which grow in the line of least resistance — 
that is, into the uterine cavity, gradually filling it. Such a uterus will be 
found enlarged, soft, and more or less boggy, A digital examination of its 
interior will reveal the cavity completely filled with a soft, friable, grayish- 
yellow, brain-like tissue. This tissue can be broken off and removed by 
the examining finger. Such a uterus compressed between the fingers 
within the vagina and the hand over the abdomen will often discharge 
disintegrating material. With the proliferation into the uterine cavity 
there is also a corresponding invasion of the uterine wall, although this is 
not so rapid. Section through the involved uterine wall or the basal por- 



PUERPERAL TUMORS. 



673 



tion of the tumor reveals a structure of more or less dense and firm consis- 
tence and of a yellowish-white color, which projects distinctly from the 
muscle. The growth gradually projects through the uterine wall and 
may present beneath the peritoneal surface. As it advances and ages, 
interference with its nutrition results and necrosis and disintegration of 
the older or superficial portions of the tumor follow. This necrotic 
material is gradually discharged and a scooped-out, crater-like cavity 
forms the uterine interior. The foul-smelling vaginal discharge is 
produced by the necrosis of the tissue. 




Fig. 524. — Adenocarcinoma of the Cervical Canal. 
Cervical canal, h. Shows extension of disease to internal os. c. Hypertrophied endo- 
metrium. 



Occasionally the cervical canal becomes completely occluded by the 
malignant growth, resulting in the accumulation of disintegrating necrotic 
tissue within the cavity of the uterus, forming a pyometra. 

Histology of Adenocarcinoma of the Body of the. Uterus. The micro- 
scopic picture presented by adenocarcinoma of the body of the uterus is 
not unform, but seems to difi'er in almost every specimen examined. Such 
differences occur in the ep thelial cells covering the surface of the endo- 
metrium and in those lining the glands. In the early stages of the dis- 
ease there occurs a piling up or stratification of the cells, which may be 
43 



674 



GYNECOLOGY. 



localized. These local proliferations gradually increase in size and pro- 
ject into the uterine cavity. In the interior of the nodules is found a 
well-marked supporting structure, composed of fibrous tissue containing 
muscle-fibres which convey the nutrient vessels. These nodular projec- 
tions vary in size. Some are short and others are long-drawn-out bodies 
resembling the benign papilloma, but the cells covering the papillary pro- 
jections are characteristic, and one of their strong features is the increased 
amount of coloring-matter they contain. The cells covering the processes 
are, as a rule, irregular in size, and rarely uniform. The cellular irregu- 
larities are marked throughout the tumor, some appearing short and others 
quite long. The epithelium covering the projections may be arranged in 




tW^r^i^' ' 







Fig. 525. — Adenocarcinoma of Body of the Uterus. 
a. Cells fracturing basement membrane and infiltrating fibrous stroma, b, b, b. Intraglan- 
dular proliferation of cells, c, c. Irregularity of cells, d, d. Epithelial cells infiltrating 
stroma. 



a single layer when the cells remain cylindrical. As a rule, more than one 
cell covering is noted, and the secondary layers are polymorphous in char- 
acter. In other instances the picture presented under the microscope 
is more of the adenoid type, and the histology of the neoplasm is similar 
to adenocarcinoma of the cervix. Numerous glands are found of 
varying size, lined with columnar epithelial cells. These are irregular 
and contain oval, deeply staining nuclei. The cells lining the glands 
may be disposed in a single layer, but in many areas an intraglandular 
piling up or stratification of the cells will be seen, and in other areas frac- 
ture of the limiting membrane with an extraglandular proliferation of the 
cells is recognized. In these areas the cells will be found wandering in 
the fibrous stroma between the glands, and this perhaps is the distinctive 
stamp of the true malignant character of the tumor. Cullen believes 



PUERPERAL TUMORS. 



675 



that in cases characterized by marked papillary arrangement the growth 
starts in the surface epithelium; whereas in the cases having distinct 
adenoid arrangement, the epithelium lining the glands has possibly 
been their origin. As the disease advances there is a disintegration of 
the peripheral portion of the growth; the surface undergoing destruction 
shows marked inflammatory infiltration, and the gland in the deeper por- 
tions of the tumor may show degenerative changes. As the necrotic 
process advances degeneration of the uterine muscle takes place and 
both muscle and glands are filled with inflammatory cells. 




Fig. 526. — Cauliflower Growth Involving the Vaginal Part. 



325. Dissemination of Carcinoma. Carcinoma is not confined 
in its development to the infiltration of the contiguous tissues already 
described, but manifests a disposition to spread through the lymphatics 
and blood-vessels to the structures more or less remote from that in which 
it originated, and here to form foci or nests of a similar character. Ex- 
perience demonstrates that this spread of the disease through the blood- 
vessels is rare. Malignant ulceration of the blood-vessels, however, 
does take place, and metastases follow through the blood stroma. Seelig 
directed attention to the fact that the capillaries for a long time remained 
intact between the existing carcinomatous projections. He once saw a 
carcinoma ring around a vein which had infected the wall of the capillary 
up to the intima. Goldman has observed penetration of the thin walls 
of the vein by cancer with alteration of the lining endothelium. In this 
case circulation was obstructed with the formation of a thrombus. Abel 
recites the history of a patient, thirty-seven years of age, who had suffered 
two months with irregular bleeding and discharge. Examination failed 



676 



GYNECOLOGY. 



to reveal any indication of involvement of the vaginal wall or parametrium. 
Total extirpation of the uterus through the vagina was done, with as ex- 
tensive removal of the broad ligament as possible. Subsequent micro- 
scopic investigation disclosed at some distance from the carcinoma, in a 
perfectly healthy looking area, a mass of carcinomatous tissue which 
infiltrated the wall of the vein. The occurrence of such conditions dem- 
onstrates the possibility of the transmission of carcinomatous masses 
through the blood stream. The principal method of extension, as already 
mentioned, however, is through the lymph-channels. The epithelial 
cones project into the connective tissue until they gradually reach large 
lymph-spaces. Having reached one of these spaces, they extend it 



^ 



-Fundus. 




Fig. 527. — Cancerous Ulceration of Intracervical Canal. 



rapidly. The more rapid development of the disease in pregnant women 
is caused undoubtedly by the increased size of the lymph-channels and the 
increased energy of the lymphatic circulation at this period. All observers 
recognize the rapidity with which malignant disease invades the tissues 
when it has developed in young women. This is undoubtedly due to 
the activity of the lymph circulation. Following the climacteric, and 
especially in senile women, the vessels become atrophied and small. 
The lymphatic circulation of the pelvis is very inactive. In such indi- 
viduals, therefore, the disease spreads slowly, and it is only when the deeper 
structures have undergone infiltration that the lymph-spaces are opened 
and the disease is transmitted more rapidly. Seelig, in his careful in- 



PUERPERAL TUMORS. 



677 



vestigations on the progress of the disease, noticed the projection forward 
of carcinomatous masses into the endotheUal hning of the lymph-spaces. 
These masses obstructed the large vessels more or less, although the 
vessels themselves could still be recognized in the structure. The largest 
lymph-spaces filled with carcinoma were situated in the margin between 
the middle and peripheral muscle layer of the corpus uteri, while the 
internal muscular branches anastomosed vertically. Investigation dem- 
onstrated that carcinomatous masses press against the connective-tissue 
or muscle-fibers until they are able to invade the lymph-spaces. Ob- 
struction of the lymph-vessels frequently results in a regurgitation, by 




Fig. 528. — Cervical Wall Infiltrated while the \^aginal Portion is Largely Destroyed. 

which portions of the malignant tissue are carried backward in the lymph- 
spaces in a direction opposite to that of the normal current. The inva- 
sion of the anterior wall of the vagina with cancerous disease, originating 
in the cavity of the uterus, may be explained thus. As the disease enters 
the lymph-spaces it is carried by the larger paths into the parametrium, 
where the lymphatics are frequently filled with carcinomatous masses. 
Emboli are carried from the lymph-spaces into the next lymphatic glands 
without the vessels themselves being involved. While it is generally 
recognized that the principal channel of invasion is through the lymph- 
vessels, yet it seems apparent that malignant disease of the uterus produces 



678 GYNECOLOGY. 

lymph-gland involvement at a later date than in cancer of other portions 
of the body. The later transmission of the disease to the lymph-glands 
is due undoubtedly to the more frequent occurrence of the disease at or 
subsequent to the climacteric, when the lymph-ducts of the pelvis have 
become atrophied as a result of the lessened activity of the genital organs. 
In women under forty years of age, however, this does not exist. It is 
in these patients that the disease makes the most rapid progress and the 
prognosis for cure is most unfavorable. Much difference of opinion ex- 
ists among investigators in this field as to the frequency of glandular 
involvement, and necessarily the decision of this question has an important 
bearing upon the plan of treatment. Ries, Pryor, Wertheim, and others 
assert that as a result of careful investigation they have found a large pro- 
portion of the next lymph-glands infected very early in the progress of 
disease. Winter's results of microscopic examination of material and 
glands removed in extirpation of the uterus shows the percentages of 
glandular involvement to vary from 20 to 50 per cent. It can be asserted 
safely that one of every three women with uterine cancer has infection of 
the glands. The investigations as to the course of dissemination justify 
the assertion that it follows the main lymphatic vessels which are in line 
with the uterine arteries from the cervix and portio vaginalis. The first 
gland is found where the artery crosses the ureter and a series of them 
are imbedded in the parametrium. The three principal stations are: 

1 . The iliac glands at the inner border and on the anterior surface of 
the external iliac artery. 

2. The hypogastric glands on the inner margin of the hypogastric 
artery and vein. 

3. The sacral glands on the posterior pelvic wall. 

Schauta agrees in the frequency of gland infection and in sixty 
carcinomatous bodies found cancer: 

Twenty-eight in the iliac glands 

Twenty in the sacral glands 

Seventeen in the lumbar glands 

Thirteen in the superficial inguinal glands 

Eleven in the deep inguinal glands and 

Nine in the coeliac glands. 

Authorities disagree as to the early invasion of the glands. Recent 
careful microscopic investigations incline Wertheim, Ries, and others, to 
the belief that invasion is early in cervical carcinoma. On the contrary, 
Blau and Dybowski in ninety-three women dying from carcinoma found 
glandular involvement in only one-third. Winter in forty-four women 
dying after operation found the glands involved in two. Schauta has 
shown that the glands may remain free in advanced cases. In fifty in- 
operable cases the glands were involved in only eighteen or 36 per cent. 
Glandular enlargement does not always mean malignant infiltration, but 
is rather an indication of the accompanying septic processes associated 
with or complicating the carcinoma. As Schauta has shown, the infection 
may pass through the near glands to infect those more remote and inac- 
cessible to operation. Those doubting early gland infection point to 



PUERPERAL TUMORS. 679 

the number of cases where operation by either the abdomen or vagina 
has been followed by failure of the disease to recur for so long a period 
as to justify the assertion that a radical cure has occurred. When recur- 
rence follows, in the majority of cases, it is found in or near the vaginal 
scar and not in the lymph-glands. Experience would seem to indicate 
that the involvement of the glands is not necessarily followed by recur- 
rence of the disease. The removal of the original source in some cases 
is evidently followed by atrophy of the infected glands. 

Cullen accounts for the failure to involve the lymphatic glands early 
in carcinoma uteri as in mammary carcinoma, by the fact that in ute- 




FiG. 529. — Circumscribed Cancer of Body of Uterus. 

rine disease there is a greater disproportion between the size of the 
epithelial cells and the lymphatic vessels; that the epithelial cells rapidly 
attain a size too large to permit of their passage through the lymphatic 
vessels, and it is only after the disease has reached the large lymphatic 
spaces and vessels that lymphatic gland infection occurs. The experience 
of operators would seem to confirm the claim of the majority of investi- 
gators that lymphatic gland involvement occurs much later in uterine 
cancer than in other portions of the body. 

Clinical Forms. We have already seen that cancer is divided, histo- 
genically, into two forms, the squamous-cell and the cylindric-cell cancer. 
Clinically it is divided into carcinoma of the portio vaginalis, of the cervix. 



68o 



GYNECOLOGY. 



and of the uterine body. It is divided clinically still further according 
to the course pursued and the physical signs presented. Thus, a coUec- 




FiG. 530. — Diffuse Cancer of Uterine Body. 




Fig. 531. — Adenocarcinoma of Uterine Body. 

tion of epithelial masses may break down upon the involved surface 
or in its center. The growth may project from the portio vaginalis 



PUERPERAL TUMORS. 



68i 



into the lumen of the vagina, or, at the same time, the connective tissue 
of the portio is occupied by the stroma and penetrated to its depth 
by cancer masses. These masses develop most frequently in cancer 




Fig. 532. — Incipient Adenocarcinoma of Uterine Mucous Membrane, a. Carcinomatous 

nodule. 




Fig. 533. — Entire Cavity Covered with Nodular Growths. 

of the portio above the level and toward the lumen of the vagina, by 
which a superficially situated tumor known as a cauliflower growth is 
formed. It exists as a more or less roundish, polypoid tumor in the 
vagina, completely distending it, and presents a tumor the size of a fist, 



682 



GYNECOLOGY. 



which becomes more contracted and firmer as the healthy structure 
is approached. The surface of the cauliflower, after desquamation of 
its pavement epithelium, reveals exposed carcinomatous masses and 
presents an irregular or papillary condition. When the disease has 
had a longer duration, with unfavorable nutrition of its interior surface 
and with compression of its vessels, large portions become necrotic and 
the cauliflower growth is covered with a grayish, greenish, smeary mass. 
Such growths most frequently start from the posterior lip. In many 
cases the disease develops in one commissure and extends from it to the 
lip; the entire portio vaginalis is rarely degenerated simultaneously. 




Fig. 534. — Communication between Bladder, Vagina, and Rectum. 

In Other cases processes of epithelial growth project into the substance of 
the portio, and in deep infiltration there is thickening of one lip of the 
commissure. In rare cases the entire portio vaginalis becomes involved 
and the more affected lip grows toward the lumen of the vagina. This 
form differs from the cauliflower growth by being polypoid and by having 
a mucous membrane drawn over it, which is rarely quite intact. Fre- 
quently the mucous membrane is thrown off in superficial layers and is 
followed by disintegration of the surface of the infiltration; or it begins 
in the center and opens through the infiltration to the outside. A smooth 
funnel or fissure wiil thus be formed, with jagged, often undermined 
borders, sharply lying toward the circumference and appearing under 
the level of the healthy surroundings. In such a fissure an ulcer will 
occasionally dissect deeply into the portio. Movable polypoid tumors 



PUERPERAL TUMORS. 



683 



will project into the ulcer or around the cervical canal, without special 
alteration of the canal itself. (Fig. 535.) Smooth ulcers are occasionally 
observed, similar to the erosion, which extends to a trifling depth. Why 
these variations in the progress of the disease exist is as yet undetermined. 

Etiology. Our knowledge of the causes of malignant disease is still 
largely speculation. Among some of the more important theories as to 
its development is : Virchow's, that while cancer is of epithelial origin, it 
is only through metaplasia or mesodermal elements that it originates; in 
other words, a transformation of the connective-tissue cells. Cohnheim 
advocates the theory that it was transmitted 
from embryonic carcinoma germs. Ribberts 
believed the epithelial cells separated from 
their connection without anaplasia; Thiersch 
and Waldeyer, that by primary growth of the 
epithelium, without alterations of biologic pro- 
perties of the epithelial cells. All agree that 
there is no distinctive cancer-cell. 

In recent years increased attention has 
been concentrated upon the determination of 
some micro-organism which shall prove to be a 
causative factor. The parasitic theory seemed 
favored by the natural history of the disease, 
its local origin, its invasion of the surrounding 
structure, and its transmission by the blood- 
and lymph-vessels. The mere fact that a 
specific micro-organism has never been isolated 
and recognized is not a convincing objection, 
for syphilis, until recently, has baffled all at- 
tempts to recognize its essential organism, yet 
no one doubted that it was so transmitted. 
Klebs and others have presented various 
micro-organisms, but none of them have 
survived careful investigation. The presence 
development of micro-organisms of various kinds, just as is found in 
other inflammatory processes, but none of them will reproduce the disease. 
Various degenerative processes in the cells have been indicated as posses- 
sing the parasitic elements, only to be proved untenable. Schwarz has 
demonstrated most convincingly that the majority of cell alterations 
favoring the parasitic theory have so far resulted from degenerative proc- 
esses of the epithelial cells, leukocytes, or their derivatives. A funda- 
mental pathologic difference exists as in the malignant form a further 
extension of the processes in the organism is influenced by the cell activity, 
and there is as yet absolutely wanting any proof of isolation of a parasite 
from which the disease can be generated. The absence of any history of 
the transmission from man to animal or from one animal to another has 
been cited. 

The occurrence of carcinoma in the penis of the male who has cohabited 
with a cancerous female is so rare as to be the exception to the rule, yet 




Fig. 535. — Cervical Canal 
Destroyed by Progress of 
Disease. 



of cancer results in the 



684 GYNECOLOGY. 

these negative arguments are only additional evidence that we do not know 
the micro-organism or its natural history. Surgeons frequently injure 
themselves while operating, but no authentic case exists by which the de- 
velopment of cancer may thus be traced. Experimental observations, 
however, have demonstrated the fact that carcinomatous tissue when 
transferred from one animal to another of the same species will continue to 
grow, while carcinomatous cells developing in the human individual when 
implanted in the tissue of another person may refuse to grow; the tumor- 
cells when placed in a raw surface distant from the original site of the 
growth may develop a secondary tumor. I have operated upon patients 
for carcinoma of the cervix who have subsequently developed secondary 
malignant disease of the abdominal incision. In one of them the disease 
developed nine months after the operation; in another after a period of 
over three years. In the latter patient the abdominal scar was involved 
in a hard, indurated mass, which upon incision revealed the intestine adher- 
ent and its walls infiltrated with carcinomatous tissue. The abdominal 
scar was excised with the affected intestine, and the patient made a com- 
plete recovery. There was no evidence of recurrence of the disease in the 
pelvis at the time of operation. 

It is more than probable that cancer owes its origin to the action upon 
irritated cells of some peculiar toxin or chemical material which is formed 
within the body. This theory seems to be confirmed by the interesting 
investigations of the processes of cell reproduction recently published by 
Ross. He was able to produce mitosis and cell proliferation by stimulating 
the living leukocytes and lymphatics with alkaloids; and the results were 
particularly active under the influence of choline, cadaverine, kreatin, 
and xanthine, extractives obtained from animal tissues. This theory 
seems further confirmed by the repeated successful vaccinations with 
cancerous tissue and the knowledge that cancerous tissue which has been 
ground with mortar and pestle until all the cells are broken may be in- 
jected beneath the skin with impunity. 

Evidently, increasing age predisposes the cell to carcinomatous de- 
generation. Statistics indicate that cancer of the uterus before the twen- 
tieth year is extremely uncommon and that it is but rarely observed 
during the next ten years. The disease perhaps makes its appearance 
most often immediately preceding or about the period of the menopause. 
Carcinoma of the body, however, usually appears later. Gusserow, in 
3385 cases, found but 2 originating before the twentieth year. It develops 
with increased frequency during the fourth decennium, but the majority 
of cases are recognized in the fifth. Thiersch believed the greater fre- 
quency of cancer with advancing age was due to atrophy of the connective 
tissue, which favored the deeper infiltration of the epithelial tissue, but 
this is a mere hypothesis. It is a question whether the apparent increased 
frequency of cancer is not due to the fact that under improved methods 
of investigation it is more apt to be recognized. Reyburn and Lewers 
attribute its frequency to diet, and direct attention to the infrequency of 
this disease among rice-eating populations. They assert that the disease 
is largely due to the consumption of large quantities of meat. 



PUERPERAL TUMORS. 685 

Inherited predisposition to the development of cancer has been re- 
garded as an important factor, but careful researches by Gusserow showed 
but 7.4 per cent, favoring such a tendency, while von Winckel found but 
6.3 per cent. Inherited lowered resistance to disease, as shown in families 
predisposed to tuberculosis and chronic renal disease, favors the develop- 
ment of malignancy. 

Twice as many women suffer from cancer as men. Next to the mam- 
mary gland, the disease occurs more frequently in the uterus. According 
to Hofmeier, fully one-fourth of all cancers in women are uterine. 

All classes of society are prone to the occurrence of cancer. It may 
occur with equal frequency in the poor or the rich. The apparently 
well-nourished woman may be unsuspectingly harboring the preliminary 
stage of the disease. 

All statistics prove that malignant disease preponderates in those 
who lead an active sexual life, especially in the multiparous woman. 
Gusserow's investigation of a large number of cases gave the average of 
fruitful labors in cancerous women as 5.1 per cent. — a proportion of 
births considerably above the average for women taken together. Ac- 
cepting the irritation theory of Virchow as a factor, we can readily appre- 
ciate the greater frequency of cancer of the cervix. The possibility of 
cancer of the cervix in the chaste virgin has been doubted, but I have 
seen several single women of unquestionable Aortue who suffered from 
cancer of the cervix. Cancer of the body of the uterus is comparatively 
more frequent in the unmarried and nulliparous women. The theory 
that cancer can be produced by excessive coition is not borne out in the 
lives of prostitutes. Carcinoma is rarely secondary in the uterus, having 
originated in the bladder or vagina. Myoma of the uterus is sometimes 
associated with cancer, but not often enough to justify the assertion that 
it is a determining cause. 

Landau is inclined to assign syphilis as a predisposing cause, but my 
observation does not incline me to accept it. Von Winckel's assertion 
that gonorrhea is an important factor in the development of cancer needs 
confirmation. With all our investigations we are driven back to irritation, 
chemical or mechanical, as a cause for malignant disease, but its existence 
does not always determine such a degeneration. We are forced to ac- 
knowledge that we do not know why cancer develops. 

Symptoms. Unfortunately, in the early stages no symptoms, either 
subjective or objective, are sufficiently prominent to give warning of 
the impending danger. As a consequence, the physician rarely has 
an opportunity for early investigation of the disease. Cancer has no 
pathognomonic signs; the principal symptoms — hemorrhage, more or 
less offensive discharge, and pain — are not constant in all cases, and 
each one or all may be produced by other than malignant conditions. 
Bleeding is the symptom of greatest significance, and may occur when the 
cervical canal is affected, though its vaginal portion is uninvolved. The 
quantity of blood lost probably will be slight and irregular, as a few 
drops after severe exertion, straining at stool, or following coition. In 
the married, post-coitive hemorrhage is a most constant and suggestive 



686 GYNECOLOGY. 

symptom. Generally the first suspicion will be awakened by an increase 
of the amount of blood lost at menstruation, or the flow will be continued 
unduly long, but neither of these is constant. In other cases the first 
intimation will be profuse bleeding. Following the climacteric, an 
occasional more or less profuse bleeding will occur, which causes the pa- 
tient to think that her menses have returned. Post-climacteric pudendal 
bleeding should always be regarded as a serious danger-signal demanding 
careful and painstaking examination. As cancer advances, hemorrhage 
becomes more active, the blood is discharged in a continuous bright stream, 
or more frequently in large clots, which are formed in the vagina. Fre- 
quently the hemorrhage is accompanied by a discharge of fragments of 
disintegrating tissue. The continuation of hemorrhage produces marked 
anemia and promotes the cachexia, but is rarely the direct cause of death. 
Unfortunately, women generally regard increased and irregular bleeding 
as a necessary concomitant to the climacteric, a view which is maintained 
too frequently by the attending physician. On the contrary, any excess 
and irregularity in the flow should always be regarded as an indication of 
grave danger, demanding most thorough investigation of the genital tract, 
supplemented by microscopic investigation, if necessary, to ascertain the 
specific cause. Nothing should be taken for granted or left to chance. 
No palliative' measures nor remedies to arrest bleeding should be employed 
prior to an examination. If the physician is unable to satisfy himself as 
to the cause, duty to his patient demands that she shall have the benefit 
of further consultation. 

Offensive discharge is next to hemorrhage in the time and frequency 
of its appearance. In an early stage the discharge is slimy and serous 
and does not have an especially penetrating nor offensive odor. As the 
disease advances and is associated with ulceration and disintegration of 
tissue, the secretion changes. It becomes yellowish; then, with a mixture 
of blood and disintegrating tissue, reddish and brownish; and, finally, a 
dark smeary mass. At first it has a stale, sweetish odor, becomes more 
disagreeable, and finally presents an intensely penetrating, stinking smell, 
alike disgusting to the patient and to her attendants. When patients 
have suffered from cervical discharge possibly for years, little attention is 
given to the increase of the amount untfl the odor becomes so marked and 
disagreeable as to demand consideration, when frequently it will be found 
that the time for successful treatment probably has passed. Decompo- 
sition of the secretion is undoubtedly due to saprophytic or putrescent 
germs, and the greater accessibility of the cervix causes the odor of its 
secretion to become affected earlier than that of the uterine cavity. 

Pain is a comparatively late symptom. The cervix, as is well known, 
is not a specially sensitive structure, and the severe pain occurs with the 
involvement of the parametrium, and is later increased by pressure upon 
nerve-trunks. In uterine cancer, or when the cervical canal is involved, 
pain is more marked, and is an earlier symptom, owing to encroachment 
upon the internal os and obstruction to the canal. The absence of pain 
leads many patients to regard the increased bleeding and discharge with 
less suspicion. When an effort is made to impress a woman so afflicted 



PUERPERAL TUMORS. 687 

with the gravity of the situation, she will doubtingly exclaim: "Why, I 
have no pain!" Slightly extended nodules near the cervix, by pressure 
upon the nervous plexuses in the retroperitoneal connective tissue, may 
produce a lively, persistent, boring pain in the depth of the pelvis, which 
is increased to an extraordinary degree by the slightest extension. It 
causes persistent lancinating pain, which is not alleviated by continuous 
rest in bed, and only the persistent use of narcotics affords any mitigation. 
As the disease approaches the peritoneal surface the pain is increased, 
serious reaction in the nutrition is induced, from which inflammatory 
adhesions with the surrounding structures result, and thus an extensive 
peritonitis is caused. The abdomen is sensitive to pressure, and, accord- 
ing to Schroder, vaginal examination reveals the uterus surrounded by 
board-like hardness. Not infrequently the symptoms may be aggravated 
by compression and narrowing of the rectum through advancing infiltra- 
tion of the pelvic connective tissue. 

The mechanical obstruction to the passage of fecal masses is generally 
associated with severe, agonizing pain; obstinate constipation arises, 
partly from the mechanical hindrance, but more from the desire to avoid 
the severe pain at stool. In cancer of the neck of the uterus, when the 
disease is transmitted to the bladder-wall, even before the entire wall is 
penetrated there is a burning sensation during the evacuation of urine, 
soon followed by tenesmus, frequent micturition, bloody, clouded, or 
purulent urine, with persistent vesical pain. With infiltration and necrosis 
of the structure a direct communication follows. The admixture of 
ammoniacal urine with the offensive vaginal discharge aggravates the 
already lamentable condition of the patient by a horrible stench. The 
profuse, irritating vaginal discharge produces an extensive erythema of 
the vulva and inner sides of the thighs, and causes the patient to complain 
of intense itching, or pruritus vulvae. 

The offensive character of the pudendal discharge may be still more 
aggravated when the disease involves the peritoneal surfaces of Douglas' 
pouch and is transmitted to the rectum and upper part of the rectovaginal 
septum, which breaks down and forms a rectovaginal opening. Occasion- 
ally, a large cloaca is formed, into which urine and feces, mixed with 
decaying tissue, are discharged, forming a most deplorable condition. 
Fortunately, the rectum is less frequently involved than the bladder. 
Frommel asserts that vesical fistula appears in one-third of all cases, 
rectal fistula in one-sixth. In the progress of the cancerous infiltration on 
either side or in front of the cervix the ureters will become involved sooner 
or later. The infiltration extends about and compresses their lumina, 
attacks the structures of the wall, and finally may occlude it completely. 
So long as the passage of urine remains free, the patient experiences no ill 
effect, but the compression causes a gradual dilatation of the ureter and 
pelvis of the kidney; a condition of hydronephrosis follows, and indications 
of uremia. If but one side is affected, the other kidney does compensatory 
work, and, beyond a possible sense of fullness and weight in the affected 
organ, there is but little discomfort. When both organs are compressed, 
uremic symptoms follow, though never violent, rarely convulsive, and 



688 GYNECOLOGY. 

gradual coma is developed, which causes increased indifference to sur- 
roundings, and fortunately, to the profuse pain. Disgust for food is 
marked. Vomiting occurs frequently, and suppression of urine may be 
present. 

Reduction in pressure from degenerative changes in the infiltration 
will often restore the caliber of the canal and permit the urine to pass. 
The sensorium will become free and so continue until new compression 
symptoms appear. An autopsy frequently discloses above the cancer 
infiltration dilated ureters, sacculated kidneys, occasionally pyelonephro- 
sis and amyloid degeneration of the kidney. Continuation of the infiltra- 
tion processes causes obstruction of the veins and arteries of the pelvis 
with edema of the vulva and of the lower extremities. Hemorrhoidal 
veins become greatly distended and cause profuse bleeding. The re- 
sistance of the peritoneum to the encroachment of the disease is marked. 
Its approach to the peritoneum is followed by reactive inflammation and 
extensive adhesions, so that cancerous nodules rarely reach the peritoneal 
cavity. Sepsis is also rare. When septic peritonitis is produced, it is 
caused by rupture, by pyosalpinx, or by penetration of the cavity from the 
cancerous nest. While sapremic symptoms are frequently associated with 
cancer, the temperature elevation is not high, for the reason that the dis- 
integrating tissue is usually shut off from the general system by a zone of 
hard infiltration tissue, which is not very absorptive. When high tempera- 
ture is present, it generally is due to an extension of the disease to other 
organs, especially the bladder. It is important to ascertain the presence 
of metastasis to other organs. In the ordinary course of the disease it 
extends to the vagina, bladder, rectum, and vulva; but it may reach the 
same glands by metastasis, as well as the ovary and retroperitoneal glands. 
Metastasis may occur into remote organs, as the liver, lungs, and kidney, 
although the number of cases in which wide diffusion occurs is compara- 
tively few. 

Cancer affects the mature, debilitated, and overworked, but is also 
found in the well nourished, and not infrequently in the comparatively 
young. (Fig. 536.) The disease in the latter is usually more rapid in its 
course. Its mere existence is an evidence of lessened resistance to its 
ravages. In the early stages, with patients in good condition, the general 
appearance would contra-indicate its existence; but with recurring hemor- 
rhage and discharge, emaciation rapidly occurs. Emaciation is more rapid 
when to the other symptoms is added pain, which robs the patient of her 
night's rest. To the drain from hemorrhage and to the loss of rest is soon 
added the depressing effect of the putrid changes, from a collection of organ- 
isms which exert a painful influence upon the general condition. The skin 
is pale, and gradually becomes a smutty yellow from increased emaciation. 
The eyes are sunken and the skin is thrown into loose folds or appears to 
be drawn over the skeleton. A patient exhibiting such changes is said to 
be cachectic. The indications of suffering are stamped upon the counte- 
nance so indelibly as to be recognized readily by the experienced observer. 
From other conditions causing uterine hemorrhage, as myoma especially, 
a cancerous patient is recognized by the tanned appearance of the skin and 



PUERPERAL TUMORS. 689 

the progressive emaciation. In myoma she may become pale, anemic, and 
often yellow, but there is no loss of flesh. Indeed, the embonpoint seems 
increased. In cancer the loss of strength is aggravated through the in- 
creased disgust for food occasioned by the foul-smelling atmosphere in 
which she is forced to live. Gusserow's view is undoubtedly correct, that 
the intense odor occasions the nausea. This is made manifest by the 
return of appetite, when by any medical or surgical procedure this symp- 
tom is temporarily removed. Vomiting is generally a late symptom, and 
most frequently the result of uremia. Rarely, it may be occasioned by 
invasion of the peritoneum. The loss of strength and flesh is progressive, 
until finally the patient dies in profound marasmus. Occasionally, she 
suffers no convulsive attacks from uremia, but just sufficient coma to 
render her insensible to the discomfort of the condition. In some cases 




Fig. 530. — Uterus Removed from an Unmarried Woman Twenty-two years of Age 



septic or carcinomatous peritonitis, pleurisy, pneumonia, lung embolism, 
or amyloid degeneration of the large glands leads to a premature end. 

Physical Signs. In the previous discussion it has been asserted that 
carcinoma has no pathognomonic symptoms, consequently its early recog- 
nition will depend largely upon the correct interpretation of the physical 
signs. Unfortunately, the patient may have no symptoms affording such 
discomfort that she will feel it necessary to consult a physician, and, as a 
natural consequence, the disease often will be in an advanced stage before 
the patient comes under observation. Many patients do consult a physi- 
cian, however, and are subjected to local treatment for other conditions 
than the grave one which should attract his attention, and thus valuable 
time is lost. It is to save such cases that, at the risk of reiteration, this 
section is written. The disease in many cases is hidden within the uterus 
and the physicial signs consequently are obscured. Fortunately, in the 
great majority of patients the disease affects the cervix and cervical canal. 
The sqaumous-cell cancer affects the external portion of the cervix and 
44 



690 GYNECOLOGY. 

appears as a small tubercle or projection upon one or the other lip of the 
cervix. In the majority a more or less extensive laceration of the cer- 
vix will be present. This tubercle will give the sensation to the examin- 
ing finger of a shot-like mass, but manipulation of it is associated with 
slight bleeding. Often the papule will be friable and can be broken off. 
As the disease advances the surface presents a superficial ulceration, which 
is above the level of the surrounding healthy structure. Its edges are 
prominent, infiltrated, ragged, often overhanging; its surface more or less 
excavated, covered with friable tissue, portions of which are easily broken 
off, and it has an infiltrated base. Pressure against such a surface with a 
sound permits the point of the instrument to become buried in friable 
tissue. The most careful examination is attended with bleeding. Fre- 
quently the vagina will be found occupied by a mass which may vary from 
the size of a filbert to that of a good-sized fist. Such a tumor presents an 
irregular, pinkish-gray surface, often covered with a greenish-yellow exu- 
date. The mass may be continuous with one lip or the entire cervix may 
be involved. The surface has a granular, friable feel, will readily give way 
under the pressure of the finger or of an instrument, and is associated with 
a very offensive discharge. Adenocarcinoma within the cervical canal 
may make extensive progress before it becomes visible. Even when 
invisible, the external portion of the cervix appears paler, and to the examin- 
ing finger, gives a sensation of hardness or resistance, firmer and less elastic 
than when due to inflammatory exudation. The cervix often will feel 
hard and dense when carefully palpated, and the pressure usually causes 
a discharge of blood from the os. Frequently the existence of a laceration 
permitting access of the finger, will reveal the presence of hard nodules, 
fragments of which are broken away easily. Or, the surfaces may present 
a large mass of infiltration, the center of which has become necrosed, 
affording an excavation with infiltrated, overhanging edges and a pulta- 
ceous, friable surface. In more advanced cases the cervix may be a mere 
shell, a large part of the uterus being involved. The infiltration can be 
recognized involving the walls of the vagina, the lumen of which is con- 
tracted by the disease. Carcinoma of the uterine body may be inaccessible 
to touch until well advanced, unless its uterine canal is subject to dilatation. 
Intra-uterine indagation reveals an outgrowth from a portion or the whole 
of the uterine cavity, which, soft, and friable to the finger, rests upon a 
firm and indurated base. When the wall of the uterus is extensively in- 
filtrated, the increased resistance can be recognized by recto-abdominal 
palpation. The penetration of the uterine wall by infiltrate is recognized 
in the nodules beneath the peritoneum, which roughen the otherwise 
smooth surface of the uterus. No discussion of the physical signs of 
carcinoma is complete without a consideration of the revelations of the 
microscope, but as they have been studied under the various forms of 
disease, and under diagnosis, I will not discuss them here. 

Complications. The more frequent complications of uterine cancer are 
myoma, ovarian tumor, peri-uterine inflammation, and pregnancy. The 
moyma usually does, and the ovarian tumor may, precede the development 
of the carcinoma. Attention has been recently directed to the association 



PUERPERAL TUMORS. 69 1 

of myoma and carcinoma in the same patient (see Fig. 500), with some 
effort to indicate a causative relation; but with the frequent occurrence 
of uterine myoma, it should not be surprising to find the coexistence of 
carcinoma even more frequently than is recognized now. Cancer begins 
in the uterine mucous membrane and subsequently may extend and in- 
filtrate the growth, which can be affected primarily only when it includes 
some glandular structure. It has occurred to me that the irritation induced 
by the prolonged use of electricity in the treatment of a fibroid growth may 
favor the development of malignant disease. I have seen carcinoma occur 
in two cases subsequent to the use of electricity, but the cases are too few 
to justify any conclusion. 

Ovarian tumor may be benign or malignant. Benign growths may 
become involved secondarily. The cancerous tumor of the ovary, how- 
ever, varies greatly in its influence and in its manner of progress from 
the benign. 

Peri-uterine inflammation may precede or follow malignant disease. In 
the latter instance it is simply a reactive inflammation by which nature 
endeavors to bar the progress of the malignant disorder. It is important, 
in investigating the case, however, to differentiate between the peri-uterine 
exudation and the cancerous infiltration, as such a diagnosis would in- 
fluence the operator in his treatment of the cancerous uterus. 

Pregnancy is a frequent complication of malignant disease. Carcinoma 
in its earliest stages does not contra-indicate the occurrence of pregnancy. 
The association of uterine cancer with pregnancy and labor presents the 
gravest danger for two human beings. The frequency of the complication 
may be determined by the consideration of the following statistics : Von 
Winckel, in 20,000 labors, reported 10, and Stratz 7 in less than 18,000; 
in the Tubingen clinic, in fifteen years, out of 5001 labors there were 7 
complicated with carcinoma. One cause of the rare association of 
pregnancy and carcinoma is the fact that the latter exists in the majority 
of cases in the later years of life after the period of fertility is passed more 
or less. The situation pf the disease will have something to do with the 
possibility of pregnancy. In 89 cases of associated pregnancy and carci- 
noma the malignant disease was found 2)^ times in the cervical canal and 
47 times in the portio vaginalis. In 4 cases the site was not determined. 

When complicated by pregnancy, the disease presents no symptoms 
essentially different from those in the uncomplicated cases, but, with the 
necessarily increased congestion of the pelvic organs, makes more rapid 
progress, so the characteristic symptoms — hemorrhage, discharge, and pain 
— rapidly become aggravated. Hemorrhage is increased, is more or 
less copious, and is associated with an offensive odor. A profuse, watery, 
exceedingly offensive discharge, at times purulent and brownish, is con- 
stant. The discharge is more abundant and putrid the more marked the 
tissue destruction in the new formation. 

It is of interest to study the effect of carcinoma on pregnancy and labor. 
The disturbances which such complications may induce in the course of 
pregnancy and labor must necessarily depend upon the situation and ex- 
tension of carcinomatous disease; sometimes they are only trifling, but 



692 GYNECOLOGY. 

occasionally they mean the death of mother and child. Progressive and 
severe hemorrhage, profuse leukorrheal discharge, associated with a 
complication of pregnancy, result in general anemia, which produces a 
gradual loss of strength. The existence of the trouble renders the de- 
velopment of cancer more rapid, and consequently early interference 
should be considered as indicated. The influence upon labor, when 
pregnancy goes to full term, depends entirely upon the situation of the 
disease. The accompanying endometritic processes can lead to placenta 
praevia. When the disease is confined to the vaginal portion of the cervix, 
it will not be impossible for labor to be spontaneous, but obstructions 
occur as soon as the portio is circularly seized in its entire circumference; 
or, if the cervical canal has become strongly infiltrated, the tissue is abso- 
lutely unyielding. Unless prompt measures are resorted to, such a 
patient may suffer from hemorrhage, exhaustion, and fatal termination, 
with the fetus still intra partum. 

Among the complications with labor are premature rupture of the 
amniotic bladder and weak labor-pains. If the pains remain active, the 
embryo is forced through, but the process results in extensive tearing of 
the cervix, which may extend to the pericervical connective tissue, cause 
the most extensive bruising and crushing of the birth canal, even tearing 
the cervix away above the infiltrated ring. Equally significant is the 
influence of pregnancy and labor upon the cancer. It was once considered 
that the existence of pregnancy had a beneficial influence on the progress 
of the cancer growth. Von Siebold is reported to have observed the spon- 
taneous recovery of genital cancer from a simultaneous pregnancy. The 
experience of recent years combats this idea. The rapidity of the growth 
depends upon the character of the disease, being much more rapid in the 
soft and medullary form than in the scirrhous variety. The labor can 
cause the most extensive destruction of the parts, and moreover, may be 
followed by infection of the tissue, leading to thrombosis, sepsis, and 
pyemia. 

Diagnosis. Hope for radical relief from cancer in the majority of 
cases will be dependent upon its early recognition. The investigations 
of Virchow dismissed the idea of cancer being in origin a constitutional 
disease and demonstrated its purely local character. A study of its 
clinical course, however, indicates that while the disease is local in charac- 
ter at its origin, transmission to the surrounding structures takes place 
sooner or later when the disease practically becomes constitutional. It is 
important, therefore, that the practitioner should recognize the gravity of 
the disease at the earliest possible moment. When the condition is one 
of doubt, the attending physician, in the interest of his patient, should 
have the doubt resolved by securing the advice of a more experienced man. 
Only by early recognition and by radical treatment before the develop- 
ment of nests in the parametrial tissue or its transmission to the more 
remote lymphatic glands, can we hope to avoid the fatal termination of this 
disease. It is well known that many patients do not appreciate the gravity 
of their symptoms and do not consult a physician until the favorable 
period for intervention has passed. It is unfortunately true that perhaps 



PUERPERAL TUMORS. 693 

a greater number are given general or local treatment or are advised to 
wait the change of life, by which time the disease has become incurable. 
This delay is frequently due to the aversion of the patient to a gynecologic 
examination, but the physician will be wise to decline absolutely to accept 
the responsibility of treating a patient who will not allow him to use the 
proper means of determining her condition. Should he treat her without 
the necessary investigation, the patient and her friends will hold him 
responsible for any untoward developments. 

The ease with which the diagnosis can be determined must depend on 
the situation of the disease. Following the classification given of cancer 
as involving the portio vaginalis, the cervical canal, and the body of the 
uterus, one is prepared to find physical signs varying with its situation. 
The association of hemorrhage, foul discharge, and pain should awaken 
a profound suspicion that only careful examination will negative. Car- 
cinoma of the portio vaginalis, as a rule, is easy to recognize. It is acces- 
sible to the investigating finger, and is exposed readily to vision by the spec- 
ulum. The most characteristic form is the cauliflower growth, which 
springs by a narrow bas^ from one lip or the other, and may fill the vagina. 
It presents to the finger an irregular, nodular mass, which bleeds upon the 
slightest touch, is very friable, and frequently covered by a greenish exu- 
date or slough. The mass may vary from a nodule the size of a bean to a 
growth the size of a fist. Instead of an exuberant growth, carcinoma may 
present an excavated cavity with indurated wall and base and undermined 
edges. In involvement of the cervical canal the external os may present 
a crater-like opening or may appear healthy. Early in the cer\dcal form 
no external indication of its presence may be apparent. The infiltration 
is confined to the mucous membrane of the canal. 

Following the rule to demand a proper examination, an exploration of 
the uterine caAdty will be required. This will be secured most effectively 
by the use of laminaria tents, which have been prepared by soaking in a 
saturated solution of iodoform and ether, or better, in tincture of iodin, 
prior to insertion. Tissue occupied by carcinomatous infiltrate will not 
dilate readily. The scrapings obtained by the curet often show irregular 
fragments which are broken or crumbled easily, in place of the long 
thickened pieces removed in endometritis. The curet, or better still, the 
finger, will disclose a roughened, indurated canal which is characteristic. 
Early in cervical cancer small indurated nodules appear, which later are 
friable. Cancer of the vaginal portion fails to involve the cervical cavity 
early, which justifies the assumption that the cervix is free except in ad- 
vanced cases. In suspected cancer the affected tissue, either in the form 
of scrapings or an excised piece should be examined microscopically. 
The excised section should include both healthy and diseased tissue, so 
that the transition from one to the other may be studied better. The 
objection has been made that the microscopical examination takes valuable 
time in the preparation of the specimens, but Smyly suggests the following 
two methods for rapid examination : First, a small piece of firm tissue is 
selected, dipped in mucilage, and placed in a freezing microtome. Partly 
frozen sections are cut, transferred to Miiller's fluid or to a 2 per cent, so- 



694 GYNECOLOGY. 

lution of potassii dichromas, and, after a few minutes to an hour, stained 
and mounted. In the second method a piece of the tissue the size of a 
bean is placed in twenty times the quantity of methylated spirit or, prefer- 
ably, in alcohol for a few hours, then a few hours in running water, and 
dipped in mucilage. Sections are made after freezing. The sections are 
removed from water to the slide, where they are stained with either 
picrocarmin or rubin and orange. These methods are too complicated 
for the general practitioner. 

Spiegelberg has emphasized the closer adhesion of the mucous mem- 
brane to the underlying tissue in cancer over that which exists in inflamma- 
tion. Naturally, the diagnosis must comprise the recognition of cancer, 
the extent of involvement, and the possibility of radical treatment. Digi- 
tal rectal examination gives information as to the infiltration of the para- 
metrial tissue. Nests or nodules may be recognized on the posterior 
surface of the broad ligament, which, with the extension of the infiltration 
lead to firm fixation. This fixation should be distinguished from inflam- 
matory trouble or cancerous infiltration. In the latter the involved sur- 
face is more irregular, presents small, hard nodilles, and a more distinct 
limitation, which can be determined through the rectal examination which 
should be a matter of routine. It can be accomplished more effectively 
if the patient is under an anesthetic. Twice I have found coexisting 
rectal cancer in women who otherwise would have been favorable cases 
for uterine extirpation. In neither of these patients did there seem to be 
any connection between the cancerous growth of the rectum and that of the 
uterus. 

The conditions which may be mistaken for cancer are : 
Chronic cervical catarrh with laceration. 
Papillary erosion of the cervix. 
Necrosis of fibroid polypus. 
Syphilitic ulceration. 

Partial retention of the products of conception. 
Chorio-epithelioma . 
Sarcoma. 

In chronic cervical catarrh with laceration nature makes an effort to 
repair the injury. The increased weight of the organ and its situation 
lead to eversion of the lips, and the fissures are occupied by hard, resistant 
tissue. The exposure of the tender cervical mucous membrane causes 
inflammatory changes, thickening and eversion, obstruction of the ducts 
of the glands of Naboth, and the formation of Nabothian cysts. The 
surface frequently is covered with granular tissue, which bleeds readily 
upon the slightest touch; the patient consequently has increased bleeding 
during menstruation, more or less bleeding upon exercise, or following 
coition. The indurated surface with a tendency to bleed, the increased 
leukorrheal discharge, the nodular condition produced by the distended 
glands, and the offensive odor associated with uncleanliness could induce 
an inexperienced physician to suspect definite cancer. Indeed, many 
cases are so close to the border-line as to render a conclusion difficult. 
Treatment will frequently establish the diagnosis. Puncture of cysts, 



PUERPERAL TUMORS. 695 

and the application of caustics cause cicatrization of the surface and dem- 
onstrate the absence of malignancy. It has been asserted that Nabothian 
cysts absolutely contra-indicate the existence of cancer, but Nabothian 
cysts observed in the immediate vicinity of cancerous degeneration 
contradict such a statement. The absence of tissue friable to the touch, 
the use of the speculum, and, when necessary, the examination of an ex- 
cised section should render the diagnosis of a benign condition positive. 

Papillary erosion of the cervix is sometimes mistaken for carcinomatous 
ulcer, but the latter is covered with friable tissue which bleeds easily. 
In carcinoma the affected structure is raised above the level of the healthy 
cervix; in erosion it is depressed. The latter has a regular outline, the 
carcinomatous ulcer an irregular, ragged line of demarcation. 

Necrosis of a fihroid polypus presents subjective symptoms similar to 
those of cancer. I recently saw a patient, a widow, forty-five years of age, 
who was suffering from a profuse menorrhagia, and a copious foul-smell- 
ing discharge. She had been assured by her physician that she was 
suffering from an incurable cancer of the uterus. The appearance of the 
patient and the odor in the room apparently justified the assertion; but a 
digital examination revealed a large mass filling the vagina. It was firm 
and resistant and could be moved about. The lower surface of this mass 
was roughened. The upper surface was smooth. The finger carried 
over it could reach a distinct pedicle, which could be traced upward into 
the uterus; the cervix was thinned, and at no point hard, indurated, nor 
infiltrated. Consequently, I did not hesitate to assure her that she could 
be cured. 

Necrosis in a fibroid within the vagina is recognized easily. The firm 
resistance, well-defined pedicle, absence of infiltration about the external 
OS, and the smooth regular outline render its benign character certain. 
A growth within the uterine cavity may be a more difficult problem. 
There a sloughing fibroid causes hemorrhage and a profuse offensive 
discharge, but the discharge usually is thinner, watery in character, and 
may contain particles of the growth, composed of sloughing tissue. The 
uterus is larger in outline, its cavity frequently open, permitting manipu- 
lation and contact of the finger with the mass within. Occasionally frag- 
ments of tissue may be removed and examined under a microscope, when 
their fibrous structure should exclude cancer. Dilatation of the uterus 
sufficient to permit the introduction of the finger discloses the cavity oc- 
cupied by a more or less resistant mass which is not friable nor easily 
broken down. 

Syphilitic ulceration should be distinguished readily from cancer by fail- 
ing to find an excavated surface with indurated base and edges, by the 
presence of other evidences of syphilis, and the absence of friable tissue 
over the ulcerated surface. Microscopic examination generally is un- 
necessary. 

Partial Retention of the Products of Conception. Retained tissues may 
be the embryonic envelope, a portion of the placenta, or blood-clots. 
These, when retained, are subject to infection, cause an exceedingly 
foul-smelling and offensive discharge, and their presence is a frequent 



696 GYNECOLOGY. 

cause of bleeding. The history of recent abortion or delivery, the dilated 
OS permitting the introduction of the finger, and the recognition of the 
retained products by exploration determine the condition. The retained 
products scraped away, a smooth surface is left, which is the normal 
uterine wall. The absence of further irritation following cleansing of the 
cavity demonstrates its true character. 

Chorio-epithelioma presents a history of previous abortion or labor 
within a few weeks or months, followed by such profuse, irregular bleeding, 
as to justify curetment which yields a large amount of soft, friable tissue. 
The hemorrhage is arrested briefly, and when it recurs, a second curetment 
reveals the renewal of similar structure. Chorio-epithelioma has a 
marked tendency to early metastasis through the blood-vessels. It 
occurs at an earlier age than carcinoma. The age of the patient, the his- 
tory of previous pregnancy, the severe hemorrhages, the rapid develop- 
ment, and the recurrence should make the diagnosis certain. The struc- 
ture can be differentiated positively from cancer only by use of the micro- 
scope. Examination reveals the material as epithelial, but differing from 
cancer in the absence of well-marked stroma. It resembles sarcoma, 
but differs from it in being composed of epithelial and not connective- 
tissue cells. Further investigation shows this epithelium to be a product 
of fetal life which has originated from the covering chorionic villi, the 
syncytial cells. 

Sarcoma causes symptoms similar to those of carcinoma. It may be 
differentiated, however, when it affects the cervix, by the polypoid or 
grape-like masses projecting from it. Where the disease involves the 
body of the uterus, the organ is likely to become much larger than is the 
case in carcinoma. Sarcoma, however, is rarer than carcinoma. The 
microscope affords the only means for arriving at a positive diagnosis. 
The structure of the sarcoma is homogeneous, and consists of connective- 
tissue cells, either round, spindle, or giant cells, without a well-defined 
stroma; the walls of the blood-vessels are invaded and made to appear as 
mere sluiceways throughout the structure. In carcinoma the structure 
is nest-like, with a well-defined stroma, the vessels are situated in the 
stroma, and their coats are not destroyed. 

It is seen that the existence of carcinoma does not preclude pregnancy. 
The existence of this complication renders it important that we should 
study its course and be able to determine its presence. The diagnosis is 
rendered easier by comparison of the hard, firm, infiltrated carcinomatous 
parts with the softer, edematous, healthy tissue of the pregnant uterus. 
The carcinomatous nodules of the portio vaginalis (vaginal portion of the 
cervix) may be recognized by touch and often as intervening between the 
finger and the parts of the child. Sometimes the initial stage of uterine 
cancer may be so slight as to be overlooked. Doubt should be dissipated 
by microscopic examination of the excised tissue. Even more difficult 
than the recognition of carcinoma is the determination of the existence of 
pregnancy in the earlier months. Pozzi claims that it is impossible to 
diagnose the existence of pregnancy with uterine cancer prior to the fourth 
month. A number of cases are recorded in which pregnancy was recognized 



PUERPERAL TUMORS. 697 

first during or following a total extirpation. Pregnancy can be overlooked 
readily in the second and third months. The earlier it is recognized, the 
better, for the increased congestion which occurs during pregnancy favors 
the more rapid development of the disease. Formerly, the existence of 
pregnancy during cancer was believed to allay or arrest the progress of the 
cancer only to accelerate it subsequent to the termination of the pregnancy, 
but careful observation has demonstrated the fallacy of this view. On 
the contrary, the increased nutrition which is directed to the uterus by the 
occurrence of pregnancy favors the more rapid development of malignant 
disease. Recognition of the existence of carcinoma, as determined by the 
microscopic investigation of the excised tissue and the simultaneous' en- 
largement of the uterus, should cause pregnancy to be suspected. 

The duration of cancer is hard to determine as it makes its appearance 
so insidiously that its beginning is rarely recognized. We have no means 
of knowing how long a period transpires between its origin and the ulcera- 
tion which drives the patient to consult a physician. Naturally when the 
disease is suspected immediate resort is made to measures for its eradica- 
tion. The form of the cancer is also a determining factor. The soft 
medullary cancer progresses rapidly and is destructive in its action. The 
final catastrophe occurs much sooner than in scirrhus. The earlier in 
life the disease develops, the more rapid, as a rule, will be its progress. 
The period of survival varies, according to different authors, between six 
months and two or three years; in squamous-cell cancer, from three to 
four years; in cylinder cell cancer, from six months to two and a half years. 
A somewhat longer period is ascribed to cancer of the body. The normal 
duration of life can be materially altered by therapeutic measures. 
Cases are seen in which, after operation, months or years passed without 
any indication of relapse. This is true not only after radical operation, 
but the patient so improves after the arrest of hemorrhage and discharge 
by some palliative measure as almost to cause the patient and her friends 
to doubt the possibility of the disease being of so serious a character. 

Prognosis. It is only necessary to study the clinical course of carcinoma 
to be convinced that the prognosis is bad. The improvement of the 
prognosis lies, first, in early recognition of the disease; second, in prompt 
resort to radical operation. The first provision requires recognition even 
before the characteristic symptoms of the disease are manifest. A patient 
in whom the irritative conditions favorable to the development of malig- 
nant disease exist should be kept under observation, and during the period 
of greatest susceptibility should be subjected to a quarterly, or at least a 
semi-annual, examination. Causes of special irritation should, as far as 
possible, be removed by appropriate treatment. Second, radical treat- 
ment should be understood as a procedure which will insure removal of the 
diseased structure within the limits of healthy tissue. To accomplish this 
with the greatest safety, the operation necessarily must be early. The 
probability of rapid invasion of the deeper structure, and establishment of 
secondary nests more or less remote from the original site, is less marked in 
cancer of the body of the uterus than in that of the cervix or the vaginal 
portion. Cancer of the uterus in a woman prior to the age of forty years is 



698 GYNECOLOGY. 

more acute in its progress and more likely to recur than in women of more 
mature years. The prognosis of the disease is materially affected by the 
thoroughness of the operative procedure and by the precautions which are 
exercised to prevent reinfection of the new wound. Inability to determine 
when and to what extent metastasis has occurred renders the surgeon un- 
able to fix the prognosis after operation with any degree of certainty in the 
individual case. An apparently hopeful one will soon relapse, and one 
for whom the outlook seems uninviting will remain for a long time relapse 
free, dependent upon obscure processes whose rationale are not fully 
comprehended. 

The outlook for length of life of the patient suffering from uterine 
cancer is affected largely by the occurrence of pregnancy as a complication. 
The prognosis of pregnancy depends upon the kind and course of labor 
and general condition of the patient; above all, upon the extension of car- 
cinoma. The more difficult the labor, the poorer the general condition of 
the patient, and the more progressive the disease, the more certain will be 
the unfortunate result and probable death. The outlook of the woman 
suffering from cancer with a pregnant uterus is far worse than for the non- 
pregnant, because pregnancy and labor occasion extremely dangerous 
results. The rapid progress of the disease during pregnancy, the severe 
trauma during labor, and the rapid carcinomatous degeneration of the 
tissue affect the result. Chantreuil reported that in sixty pregnant 
carcinomatous diseased women twenty-five died during or shortly after 
childbirth. Cohnstein, in one hundred and twenty-six cases, saw seventy- 
two die. Hermann had one hundred and eighty cases in which seventy- 
two died. The uterine rupture alone had six victims out of Chantreuil's 
sixty cases; eleven out of Hermann's one hundred and eighty; nineteen out 
of one hundred and twenty-six women, according to Cohnstein, died 
undelivered — about 8.1 per cent, of all the cases. Under the uniform 
methods of treatment employed of late years, the mortality is somewhat 
decreased. It is now admitted that the treatment of complications of preg- 
nancy must be consigned to operative procedure, either gynecologic or 
obstetric. Formerly the treatment was limited to artificial abortion and 
premature labor. But little experience, however, was required to demon- 
strate that such measures were ineffective. The course then advised was 
to prolong the pregnancy as long as possible with a view to securing 
viability for the child, and the obstetric operation became the important 
consideration. Later experience in the various methods of treatment has 
led to the following conclusions : i. In cases in which the cancer has reached 
a stage where radical operation is impracticable every effort should be made 
to prolong the pregnancy until the child becomes viable; 2, where the 
patient, however, is recognized to have the disease in its early stages, with 
a reasonable hope for successful removal, the ovum should not for a 
moment be permitted to prejudice the chances for the mother, and radical 
operation should be undertaken without reference to the child. 

Treatment. Study of its anatomic structure and progress of develop- 
ment indicates that cancer originally consists of a primary nest, from which 
invasion of the surrounding structures occurs. The rational treatment, 



PUERPERAL TUMORS. 699 

then, consists in the removal of the diseased structure within healthy 
limits. Upon the extent of involvement will depend our ability to remove 
completely the disease, and hence the division into two classes — radical 
and palliative. The following scheme represents the methods of treat- 
ment which may be adapted to each class: 



Radical. 



f I. Partial extirpation, Vaginal 

J 2. Total extirpation, 



B. Palliative. 



Vaginal. 

Abdominal. 

Sacral. 

Cureting, 
Caustics. 
Cautery. 

4. Injections, f Hypodermic. 

\ Clean.sing. 

5. Anodynes. 



3. Palliative operations, 



326. Radical Operations. Partial Extirpation of the Vagina. As 
carcinoma uteri largely preponderates in the cervix, it is quite conceivable 
that the early operative procedures were directed to the extirpation of that 
section of the organ involved. Von Grafenberg, as early as 1600, reported 
that the uterus had been normally extirpated in a number of cases, but it is 
most probable that the majority of these were amputations of the cervix, 
particularly as the subsequent continuance of menstruation is noted in 
several women, and, indeed, the birth of children. In the early cases 
hemorrhage was controlled by styptics, and many of the patients suc- 
cumbed to hemorrhage and sepsis. 

Partial extirpation has remained, until the last twenty years, the princi- 
pal, if not the exclusive, operative method of combating carcinoma. It 
consisted in the removal of the diseased parts with knife or scissors, and 
the control of hemorrhage with the cautery or strong fluid caustic. The 
difficulty in controlling hemorrhage led to the employment of the chain or 
wire ecraseur, by which the diseased tissue was crushed. The use of the 
galvanocautery loops was a marked improvement. The galvanic loops 
were placed upon the cervix above the margin of the disease and tightened 
until the cervix was amputated. C. Braun and Byrne practised this pro- 
cedure extensively with extraordinary results. The latter made it still 
more effective by substituting the galvanic knife for the loop. 

Neither the employment of the ecraseur nor the use of the loop can be 
considered as an ideal surgical procedure. With the first, injury of the 
neighboring organs cannot always be avoided, and, with the second, it is 
not always possible so to place the loop that amputation of the vaginal 
portion of the cervix results with certainty in healthy tissue. A more 
progressive method was instituted by returning to amputation with the 
knife and union of the wound surfaces by sutures. The procedure was 
introduced by Hegar, who made a funnel-shaped incision. Schroder 
perfected supravaginal amputation of the cervix, a method capable of 
meeting all the requirements of the present partial uterine extirpation per 
vaginam. 



700 GYNECOLOGY. 

Amputation of the Cervix with the Galvanocautery Loop. The prepara- 
tion for vaginal operation (§ 131) is made, exercising care to penetrate 
and disinfect the neck. The cervix is exposed with specula or re- 
tractors, seized and drawn upon with hook forceps which dip into the 
healthy tissue, while the platinum loop is placed as high as possible, com- 
ing immediately under the transverse folds which indicate the position of 
the bladder, and is so tightened that it cuts into the tissue. As the exci- 
sion progresses the vagina is protected from heat by wooden plates and 
syringed several times with water in order thus to cool the tissues and 
preserve them from burning. The wire must be kept at a red heat in 
order that the surfaces shall be well scorched. The wire should be tight- 
ened slowly until the cervix is cut through. When the operation is 
accomplished with due deliberation, there is no tendency to subsequent 
bleeding. The higher the wire is placed upon the cervix, the more prob- 
able it is that Douglas' pouch will be opened. The occurrence of such 
an accident, however, requires no more consideration than to pack the 
cavity with iodoform gauze. By using the galvanocautery knife Byrne 
improved the operation. He cut around the vagina, separated it from the 
cervix which he was enabled to remove at a higher level. 

Hegar^s Operation. The funnel-shaped amputation of the cervix 
described by Hegar is accomplished as follows: The cervix is fixed by 
double tenacula and drawn downward. A knife is introduced as far 
away from the limits of the disease as safety for the bladder and ureters 
will permit, and is carried about the cervix, held at such an angle as to cut 
out a cone-shaped mass, the apex of which would be high in the cervical 
canal. The hemorrhage is controlled by sutures and tamponade. Baker 
operated in a similar manner, but controlled the hemorrhage with the 
cautery, while Van de Warker cauterized the surface with zinc chlorid. 

Schroder^ s operation is a supravaginal amputation, as follows: The 
cancerous portion is exposed by Simon's retractors. With a sharp curet 
all removable tissue is scraped away from the new formation until the curet 
reaches firm tissue, when the entire bleeding surface is scorched with a hot 
iron, the vagina being protected from the heat and frequently irrigated as 
the operation proceeds. The cervix is seized with a vulsellum and drawn 
downward as far as possible. An incision — if possible, one centimeter 
from the disease margin — is carried about the cervix; with the index- 
finger or a gauze pledget the bladder is separated bluntly from the anterior 
uterine wall. The bladder and ureters are thus shoved upward, when 
the anterior wall of the neck can be removed at a high level. In this opera- 
tion Douglas' space is frequently opened, but the cervix is retained in con- 
nection with the lateral parametrium. The cervix is pulled to one side, 
while with a Deschamps needle a ligature is passed as far away from the 
cervix as possible, tied firmly, and the tissue cut between the neck and 
the ligature. If the tissue is thick, a number of ligatures may be applied, 
one above another, and when the opposite side is likewise treated, the 
cervix is cut away. When necessary, all the cervix below the internal os 
can be removed. If Douglas' pouch is opened, the circumstance 
may be made useful in closing the parametrium, as the needle can be 



PUERPERAL TUMORS. 70I 

passed upon the finger, introduced through the opening. The cervix 
is then amputated at the level of the internal os. The section is made 
through the anterior vaginal v/all to the cavity, and, before proceeding 
further, the anterior vaginal wall is stitched to the anterior cervical wall 
with two or four sutures. The amputation is completed by cutting through 
the posterior wall, when the surfaces are sutured as in the anterior. 
A number of sutures are now applied to the lateral portions of the wound 
to insure closure. The sutures should be carefully placed in the lateral 
angles in order to secure the uterine arteries. When they are secured 
ineffectually, hemorrhage may be free and threaten a fatal result. The 
patient can arise in from ten to twelve days and be discharged after 
eighteen to twenty days. 

The high amputation of the cervix has had many advocates, who 
champion it in preference to extirpation as being safer and less prone to 
subsequent relapse. The employment of the galvanocautery knife may 
produce a beneficial influence in the destruction of cancer nests which 
would be overlooked by the scalpel. An objection to the operation 
is that the cervical opening may contract and become closed, causing 
subsequent distress, and necessitate further operative procedure to relieve 
the dysmenorrhea or hematometra. Cases of pregnancy have been 
reported where the difficulty in labor was so great, because of the scar 
tissue, that operative delivery was required and the patients died. Similar 
experience has been observed in the Hegar operation, owing to the difficulty 
in introducing the sutures. All these disadvantages are avoided by the 
Schroder operation. 

The investigations of Seelig have demonstrated that infection has been 
carried through the lymphatics to the cervix, and even to the body, of 
the uterus. Such an occurrence would render anything less than extir- 
pation of the entire organ of no service, and no positive means exist 
for determining when it has taken place. An additional reason for 
preferring the entire extirpation is that the cicatricial tissue is always 
irritable, and is a source of danger in a woman predisposed to undergo 
malignant change. The removal of the uterus and ovaries brings about 
a lessened congestion of the pelvic tissues, and will certainly leave the 
patient free from subsequent periodic engorgement of the pelvic structures. 
The cases suitable for the partial operation are not frequent. 

Total extirpation of the uterus in isolated cases has been mentioned 
as having occurred at various times during the eighteenth century, 
but it remained for Czerny and Freund to formulate procedures which 
have led to more complete and satisfactory methods of vaginal and ab- 
dominal hysterectomy of the present day. 

Total extirpation may be undertaken in one of two stages of devel- 
opment: first, when no evidence of involvement of the parametrium 
exists, when the object is to eradicate the disease by ablation of the organ 
and the surrounding portions of the vagina and parametrium, or to 
operate within healthy tissue; second, when there is some involvement 
of the parametrium with fixation of the uterus. The latter operation 
is not curative, but may ameliorate symptoms. 



702 GYNECOLOGY. 

In performing the radical operation two purposes should be kept in 
mind: i, To keep beyond the confines of the disease by operating in 
healthy tissue; 2, to protect the patient from any possibility of reinfection. 

1. Recognition of the processes of development and extension of 
cancer, is too uncertain in any individual case for the surgeon to be able 
to determine definitely, prior to operation, that circulatory or irritative 
extension has not involved the parametrium beyond the safe limits of 
operation. In some this transmission may occur early in the disease, 
in others late, so that usually in a woman with but slight involvement 
and no demonstrable evidence of extension a favorable prognosis is 
given. However, in these cases the surgeon frequently is horrified to 
find a recurrence after a very brief period, while in others the entire 
vaginal cervix may be destroyed, a radical operation is done with a 
hope of amelioration only, but the patient remains free from recurrence 
for years or even permanently. 

2. The possibility of reinfection or of implantation of portions of 
cancerous structure on a healthy wound and the reproduction of the disease 
from it has been questioned. Such an explanation for the redevelop- 
ment of cancer in a wound where microscopic investigation indicated that 
the operator was well beyond the confines of the disease seems rea- 
sonable. The opponent of infection, however, justly instances the pos- 
sibility of metastatic nests in the parametrium, discoverable only by the 
microscope, from which the recurrence has followed. Such allegations 
for the vicinity of the wound are difficult to combat, but if, in a single 
case, the disease can be transplanted to the abdominal wound in an 
abdominal hysterectomy, it should be considered proof that such im- 
plantation may occur, for that region would be entirely out of the usual 
route for metastatic extension. Such an infection came under my 
observation in the practice of one of my colleagues, in a young unmarried 
mother. Within two months after an abdominal hysterectomy nodular 
masses were observed in the abdominal wound, which subsequently 
progressed. In two of my cases implantation has occurred. In both 
involvement was extensive and the cervix was occupied by a squamous- 
cell carcinoma. The first patient had a sinus in the abdominal wall 
following a stitch abscess in which proliferation of the epithelium oc- 
curred, resulting in a spreading sore which involved the tissue circum- 
jacent to the abdominal incision. 

As this patient had pelvic involvement as well, the possibility of 
continuous extension must, of course, be considered, although I was 
apparently able to excise the infected abdominal tissue without opening 
the peritoneal cavity. The second patient, an unmarried woman, 
underwent operation June 19, 1900. The entire cervix was involved in 
so extensive a cauliflower growth that her attendant, a surgeon of con- 
siderable experience, questioned the advisability of operation. She 
was exceedingly anemic and broken down by repeated hemorrhages. 
She was continually nauseated and vomited everything taken for five 
days subsequent to the operation. At the close of a week it was found 
that all the sutures had cut through, the wound was gaping, and the 



PUERPERAL TUMORS. 



703 



intestine protruding. The wound had been closed with silkworm-gut 
sutures for all the tissues above the peritoneum, and continuous chromic 
catgut for the latter and the aponeurosis. The intestines were packed 
back with gauze, and a week later the wound was closed with through- 
and-through silkworm-gut sutures under cocain anesthesia. The 
patient left the sanatorium five weeks subsequent to the performance of 
her operation, with good union in the abdominal wound. Much to the 
surprise of her attendant and myself she enjoyed, barring a very small 
ventral hernia, excellent health for over two and one-half years. She 




Fig. 537. — Formation of Flap to Cover Diseased Surface Preliminary to Operation. 

then began to have discomfort and swelling in the line of the wound, and 
a lump could be felt which was thought to be a strangulated and inflamed 
projection of the omentum. However, the mass gradually increased in 
size and became painful, and, therefore, a provisional diagnosis of re- 
current malignant disease was made. This was excised June 18, 1903, 
three years from the date of her previous operation. Nearly four years 
after the second removal she developed a recurrence in the pelvis. She 
died June, 1908, eight years after the original operation. At the second 
operation a mass of infiltrate as large as a hen's egg occupied the center 



704 GYNECOLOGY. 

of the cicatrix. The omentum and a portion of the ileum were adherent 
and had to be separated with scissors; a portion of the intestine also 
was involved in an annular band of tissue, for which three inches were 
excised and united by an end-to-end anastomosis. Careful examination 
failed to reveal any other evidence of the disease, the pelvis disclosed no 
sign of any infiltrate or glandular enlargement, although careful obser- 
vation was made. It may seem that the two and one-half years which 
intervened before the development of this growth would argue against 
implantation, but is it any more difficult to consider transplanted cells 
as lying latent and inactive in this area than it is for those which have 
been transmitted to the parametrium to develop within the five years, 
a period which all authorities admit should transpire before a case can 
be pronounced as cured ? 

Whether we accept or reject the theory of infection, the precautions 
taken to prevent it are only such as will be of service in rendering the 
parts sterile and in preventing infection from pathogenic germs, which 
every one will admit are present. 

Preliminary Treatment. In every extirpation of the uterus, whether 
per vaginam or through the abdomen, in addition to the preparation 
indicated in § 131, precautions should be exercised to remove all diseased 
and disintegrated tissue. The surface should be gone over with a 
sharp curet, all loose and ragged edges trimmed with scissors, and 
the superficial structures thoroughly scorched with the thermocautery. 
Sutures should then be introduced to close up the diseased surface. If 
the entire vaginal cervix is more or less involved, incisions should be 
made upon each side which will permit flaps to be turned down and 
sutured over the diseased structures. In many cases a number of tenaculi 
may be used for the double purpose of closing the cervix and for trac- 
tion and control of the cervix. The vagina should be irrigated contin- 
uously during the process of closing off the diseased surface and this pro- 
cedure followed by careful sponging with a solution of sublimate in 
alcohol (1:500). 

Vaginal Hysterectomy. Many isolated cases of extirpation of the 
uterus per vaginam are found in the literature of the last century, notably 
those of Langenbeck and Sauter-Recamier. Czerny, on August 12, 
1873, revived the operation. The operation has also been variously 
modified. The following method should be pursued: 

1. After the preliminary preparation directed (§ 131), place the 
patient in the lithotomy position, expose the uterus with an Edebohls 
speculum and lateral retractors, make traction upon the cervix with 
double tenaculum, vulsellum, or a silk loop passed through it, draw it 
down as near to the vulvar orifice as possible, and close the cervix by 
sutures, making flaps where necessary to cover the diseased tissue. 
Sterilize the hands and the instruments so far used. It is well to wear 
rubber gloves for this procedure and to change them before the next. 

2. Separate the cervix with scissors, knife, or thermocautery (prefer- 
ably the latter) from the vaginal wall by an ovoid incision, extending it 
as far away from the diseased tissue as safety for the bladder and ureters 



PUERPERAL TUMORS. 705 

will permit. This can be carried higher on the posterior surface without 
the fear of injuring the rectum. The thermocautery knife has the ad- 
vantage that it decreases hemorrhage, destroys additional infected tissue, 
and prevents immediate union, thus favoring better drainage. 

3. Push back the bladder from the anterior wall of the uterus and 
from the broad ligaments with the finger, a sponge or with the handle 
of a knife. Where desirable to remove a large portion of the parametrium, 
expose each ureter and place upon it a traction ligature, as suggested by 
Bovee, when the uterine artery can be traced out and ligated near its 
origin. 

4. The section of the portions of broad ligaments containing the 
uterine arteries permits the uterus to be drawn out still further. If it 
has not already been done, the peritoneum should be opened back and 
front when the uterus is held only by that portion of the broad ligaments 
containing the uterine arteries. The left broad ligament external to 
the tube and artery is ligated, secured with a hemostat, and cut toward 
the uterus. The remaining broad ligament — the right — is easily treated 
in the same manner. Bleeding vessels should be sought, secured with 
hemostats and ligated. 

5. Unite the peritoneal surfaces front and back to the edges of the 
vaginal mucosa. Secure the stumps in the angles of the wound with 
sutures so introduced and tied that they act as an additional ligature. 
Close the intervening opening between the stumps by a purse-string suture 
in the peritoneum, then push back the stumps behind the vaginal wall and 
suture the vaginal edges. Cleanse the cavity and pack the vagina loosely 
with iodoform gauze. 

All sutures should be of catgut, as silk is likely to become infected, 
produce a discharge, and maintain a sinus until it comes away, which 
may require months, unless previously removed. Such a state keeps the 
patient in constant apprehension that the disease is returning. The dis- 
position of the ovaries and tubes will depend upon their situation and the 
extent of the disease. If they are easily displaced downward, they should 
be removed; if high up, requiring considerable manipulation to displace 
them, they may be permitted to remain, as they cause no trouble. Before 
closure the wound should be inspected carefully for any bleeding vessels, 
as it is not impossible that a ligature may slip and a fatal hemorrhage 
result. Bleeding points should be picked up and secured with separate 
ligatures. 

The treatment of the wound must depend on the condition of the patient. 
Thus, if she is much debilitated and it is undesirable to keep her long under 
an anesthetic, the wound may be packed between the stumps with iodo- 
form gauze, carrying the latter sufficiently high to prevent the intestine 
from coming in contact with the raw surfaces. The gauze packing is 
placed lightly in the vagina and the vulva covered with a pad. This 
packing, when the blood control has been complete, may be permitted 
to remain from four days to a week. Upon its removal the cavity is 
irriga.ted with a i per cent, salt solution, and may be repacked lightly, 
although the packing should not be carried as high as the first portion. 
45 



7o6 GYNECOLOGY. 

The anterior and posterior walls of the vagina are thus permitted to fall 
together and become adherent. If there is no tendency to displacement 
of the viscera downward and the belly of the patient is not distended, 
the gauze need not be replaced, and the vagina may be kept clean by 
irrigation. In relaxed vagina, or when the condition of the patient will 
permit of more time for the operation, the ends of the broad ligaments 
should be united laterally in the vagina by a deeply passed suture, which, 
when tied, holds up the vagina and avoids its subsequent relaxation for 
want of support. For further steps in the procedure see 5. above. The 
patient should be confined to bed for two weeks ; frequently cases are per- 
mitted to rise earlier than this, but the long rest in bed is no disadvantage. 
The pelvic floor is firmer and less likely to prolapse subsequently. 

Various modifications of the operation of vaginal hysterectomy have 
been suggested. Three years after Czerny introduced it, Sanger was able 
to collect thirteen different methods of operating, and each year since 
other modifications have been suggested. Mikulicz was the first to use 
the curet. Billroth and Olshausen added scorching the surface with 
the thermocautery; others, in addition, cauterized with carbolic acid or 
chlorid of zinc, or used iodoform, liquor ferri chloridi, alcoholic bromin 
solution, and absolute alcohol. Tauffer made his preliminary prep- 
arations several days before the operation, and Leopold advocated dis- 
infection as the first step. Schauta began the operation with the ther- 
mocautery. Bottini, Wecchi, and Calderini amputated with the gal- 
vanocautery loop, and followed with extirpation. When cancer is situa- 
ted high in the cavity of the uterus, antiseptic syringing is practised, the 
cavity packed with iodoform gauze, and the os closed over it with sutures 
or with fixation forceps. In order to limit the discharge of secretion in 
carcinoma of the body, Schauta introduced a tupelo tent into the cervix. 
This tent was somewhat constricted in the middle from perforation, and 
a thread was introduced, the ends of which were armed with needles. 
These needles perforated the- cervical canal anteriorly and posteriorly, 
and the ends of the suture were tied over the end of the tent. The swell- 
ing of the tent acted as a plug to the cervical canal. Mackenrodt intro- 
duced the formation of flaps from the anterior and posterior vaginal sur- 
faces, which we have described. Landau advocated an ovoid incision, 
the posterior surfaces somewhat higher than the front, as such an incision 
gave greater accessibility to the operation field. Doyen lengthens the 
circular incision by one right and left, in order to create a still larger open- 
ing, and especially to be able to separate about the bladder and the ureters 
more securely. Fritsch incised both sides of the vagina; the base of the 
broad ligament is cut and tied, so that in this manner the uterus is easily 
movable and readily drawn down before the cervix is separated from the 
anterior and posterior union. Schatz opens into Douglas' space; then 
the uterus is completely freed from its lateral union, and, finally, the 
bladder is separated from the cervix. The ureters have been injured in 
this method of operating. Billroth separates by degrees the broad lig- 
ament, ligates the individual vessels, and fastens the broad ligament 
in a properly prepared fixation forceps. Schroder drew the. uterus 



PUERPERAL TUMORS. 707 

through the opening of Douglas' space into the vagina. This procedure 
is not always performed with ease. Fritsch rotated the uterus through 
the anterior peritoneal opening. Olshausen operated with the uterus 
continually in situ, and endeavored to separate it first on that side which 
showed the least invasion by cancer. Corradi and P. Miiller rendered 
removal of the uterus easier by dividing it into two portions by a sagittal 
section, and then removing each half singly. Kelly divides it into four 
or more. This procedure, without question, renders the removal of the 
uterus more easy, but if we believe in the reimplantation of the cancer 
cell, it greatly increases the danger. The ligation of the broad ligaments 
has also given great variety of procedure. Some ligate small sections; 
others ligate in mass. Olshausen, in the beginning, attempted to surround 
the broad ligament with a single ligature, but the stump would shrink 
and the vessel retract from the ligature and considerable hemorrhage 
result. Liebmann attempted to ligate the parametrium in such a man- 
ner that the ligature is knotted on the vaginal mucous membrane in order 
to limit its slipping. The superior part of the broad ligament, with the 
spermatic vessels repeatedly slips from the ligature and requires supple- 
mentary ligation, which is accomplished with great difficulty. Veit 
fastens the superior part of the stump with hook forceps and ties the liga- 
ment behind them. 

With regard to the removal of the ovaries there has been considerable 
discussion. Czerny, in his first case, removed the appendages supple- 
mentary to the removal of the uterus. Schroder, Olshausen, and others 
leave them when no indication of disease is found. Von Teuffel and 
Kaltenbach urge their removal; the latter emphasized the possibility 
of infection of the peritoneum by leaving inflammatory diseased portions 
of the tube. The retention of the appendages in carcinoma of the uterine 
neck is not found to favor the appearance of relapse. The course of the 
lymph-channels arising from the cervix has no relation to the appendages 
of the uterus, which always should be removed whenever pathologic 
alterations are recognizable. After Reich, in several cases of carcinoma 
of the body, had demonstrated cancerous disease of the ovary, the removal 
of the appendages was advocated in all cases in this form of uterine cancer. 
Formerly surgeons employed irrigation freely with strong antiseptics 
during the early part of the operation. To-day, the majority of gyneco- 
logists, after radical disinfection of the field of the operation, proceed 
with sterilized instruments without irrigation. Irrigation should be 
employed only when necessary to cleanse the field, and it is better 
then to use nothing stronger than normal salt solution or a i per cent, 
saline solution. 

The vaginal operation will be especially difficult if the canal is narrow 
and rigid or the uterus very large. Under such circumstances the 
majority of operators have incised the vaginal wall or the paravgainal 
tissue, which increases the lumen of the vagina considerably Von Winckel, 
in one case with enormous narrowing of the vagina and a large uterus, 
split the entire rectum and rectovaginal septum up to the vaginal vault. 
The large vaginorectal wound was sutured with silk, and recovered hj 



7o8 ' GYNECOLOGY. 

primary intention. Diihrssen made a deep vaginal incision, which 
penetrated from the vaginal vault and completely opened the ischio- 
rectal cavity and the entire vagina. Section on the right side penetrated 
the vagina, and also the rectum, to the depth of six or seven centimeters. 
By this incision not only the vaginal tube, but also the surrounding 
muscular structure, the levator ani, and the constrictor cunei are separated. 
The direction of the incision is in the middle line, between the tuber 
ischii and the anal opening. By such an incision the entire field of the 
operation is incidentally increased, and the resistance of the soft parts 
of the pelvic cavity is removed. The hemorrhage from the vagino- 
intestinal incision is either controlled by ligature or through pressure 
of retractors. After the removal of the uterus the wound is closed by 
sutures. After such an incision relapses have occurred in the scar 
tissue, which are evidently infection relapses. Schuchardt creates a 
still larger accessibility to the field of operation by opening more widely 
the ischiorectal cavity. He makes two accessory incisions. One splits 
the entire lateral vaginal wall, from below to the neck; on the other side a 
long vaginal incision from behind progresses to the sacrum and encircles 
the rectum, bow-like, in an incidental sagittal section. The long incision 
is made upon the side in which the parametrium is involved strongly, 
and extends to the outside of the convex bow at the side of the anus. 
The extirpation of the uterus in these operations differs from the usual 
vaginal extirpation only in that the parametrium has been opened up so 
that some cancerous nodules can be removed therefrom without exposure 
of the ureters. The vagina is closed from above downward by knotted 
suture. 

While it cannot be denied that these extensive vaginal incisions permit 
greater freedom in the manipulation of the uterus, the ease with which 
it can be reached from above would seem to contra -indicate such a method 
•of procedure, especially in view of the increased danger of reimplantation 
upon parametric tissue which must be associated with so extensive a 
dissection. To facilitate the removal of larger portions of the parame- 
trium with safety, Pawlik, Kelly, and Clark advocated prior to operation, 
the introduction of catheters into the ureters to establish their position 
more definitely and permit, with safety, the more extensive removal of 
the parametrium. The dissection and guarding of the ureters, as Bovee 
suggests, are preferable and safer, for one case of catheterization has been 
reported in which the catheter was broken off and the patient died. 
Catheterization inflicts more or less trauma and, therefore, predisposes 
to infection. Mackenrodt, in total extirpation, cuts about the vagina 
some distance from the portio and prepares anterior and posterior flaps, 
which are drawn over the portio and sutured so that the diseased tissue 
is completely covered. He splits the anterior vaginal vault by a median 
incision from the urethral swelling to the circular incision. The acces- 
sibility of the operation field is still further increased by a deep vagino- 
intestinal incision. The bladder is dissected from the cervix, and es- 
pecially from the broad ligaments, and therewith the ureters are separated 
some distance; and, finally, the uterus, with as large a portion as pos- 



PUERPERAL TUMORS. 709 

sible of the parametrium, is extirpated. The peritoneal wound is closed 
after the contraction of the stump, the vagino-intestinal incision narrowed 
by suture, and the vagina, with the supravaginal wound, packed with 
iodoform gauze. Later, Mackenrodt performed an operation in which 
the extirpation of the uterus and of the greater part of the vagina was 
accomplished with the hot iron. He believes that a larger portion of 
the vagina must be removed than is customary, because we do not know 
that a latent contact infection of the vagina does not already exist. He 
performs the operation as follows : 

With cutting instruments, Paquelin cautery, or galvanocautery the 
entire vagina, or at least the upper half of it, is separated; a vaginorectal 
incision is made which extends to the portio and lays open the operation 
field; then the vagina is seized with forceps and separated downward by 
hot iron. If the upper part of the vagina only is removed, we begin with 
a circular incision in the middle of the vagina. After extirpation of the 
vagina the portio is secured with forceps and Douglas' cavity is opened 
with a hot iron. The bladder and the broad ligaments are separated 
from the cervix by a properly constructed shovel forceps, drawn as far 
as possible to the outside, and separated by the cautery. After the sepa- 
ration of the base of the broad ligament of both sides spurting vessels 
are seized with Koeberle forceps, which are placed in the higher part 
of the broad ligament, separated by the cautery, and the stump scorched. 
The now very movable uterus is easily inverted. The upper parts of 
the broad ligaments are fastened with Richelot's clamps and a ligature 
is placed on each side, after which the separation of the stump results. 
After the removal of the uterus the rectovaginal incision is closed by 
sutures, when, in spite of the scorching, primary union usually is ob- 
tained. The perineum is not sutured. The burned cavity is filled with 
iodoform gauze. Elevation of temperature follows. Of ten cases sub- 
jected to this operation, two suffered from sepsis. 

Byrne has removed the entire uterus by the galvanocautery, but used 
the knife instead of the loop. Winter and Frommel combat the possibility 
of the danger of contact infection of the vagina being great enough to 
justify such a procedure. Czerny, Franck, and others have pursued 
the method suggested by Langenbeck who separated the uterus from its 
peritoneal envelop, and united by sutures the several resulting tears in 
the peritoneal covering. This operation sometimes is easily done, but at 
other times is extremely difficult. Richelot and Pean advocate the use 
of clamps instead of the ligature. The preliminary steps of the operation 
are performed similarly to those already described. After opening the 
peritoneum in front of and behind the uterus, the organ is held by the 
broad ligaments, through which enter the uterine and ovarian arteries. 
Clamp forceps are applied at each side of the cervix, upon about one- 
half of the broad ligament, and the structure is cut between the cervix 
and the clamp. The uterus is drawn down, if preferred, and the fundus 
is brought forward and through the anterior fornix; clamp forceps are 
applied from above upon the remaining portion of the broad ligament. 
The section between the clamp and the uterus frees that organ, which can 



7IO GYNECOLOGY. 

be removed. The clamps are then held apart, the surfaces are separated 
by retractors, and careful inspection is made to determine that all 
bleeding vessels are controlled. Any spurting vessels should be secured 
with smaller clamp forceps or the arteries should be ligated. Iodoform 
gauze is carried into the vaginal canal between the clamps to the point 
at which the peritoneum has been separated, and is packed loosely be- 
tween the clamps. The gauze should be carried over the end of the clamps, 
so that the coils of intestine may not impinge against them and become 
injured. The operation has the advantage that it can be performed 
very expeditiously, and requires much less time than the application of 
the ligature. It has the disadvantage that the tissue within the grasp of 
the clamp undergoes sloughing, causes a foul discharge, an offensive odor, 
and sloughing tissue which makes the infection of the peritoneal cavity 
easy. The convalescence of such patients is usually attended with con- 
siderable elevation of temperature. 

Tufher reports twenty-seven cases of vaginal hysterectomy without 
the use of forceps or ligatures. The uterus was bisected, one-half drawn 
out of the vulva, the finger passed behind the upper part of the broad 
ligament, and the included tissue grasped between the blades of a power- 
ful clamp, the angiotribe, which is tightly screwed. The tissues are thus 
crushed and the artery is occluded. After the crushing of the tissues the 
ligament is cut through and the upper part of the broad ligament crushed 
in a similar manner. It is very important that the handle should be 
secured as tightly as possible and the blades kept in the axis of the vagina. 
In none of the cases reported had any accident occurred during the opera- 
tion and absence of hemorrhage was particularly noted. Dr. Newman, 
of Chicago, also advocated quite strongly the use of the angiotribe, but it 
cannot always be relied upon for the control of hemorrhage, and in some 
cases tears the vessel, making its control by ligature difficult. Dr. 
Downes, of this city, has greatly improved upon this method by the use of 
electro-hemostasis. 

The late Dr. Joseph Eastman placed the patient in the Sims posi- 
tion, stretched the anus to allow greater readiness of access to the pelvic 
cavity, retracted the perineum with a Sims speculum, and made an 
incision about the uterus, which opened the Douglas culdesac poste- 
riorly and between the bladder and uterus anteriorly. He then passed 
a curved staff over the broad ligament, by which a ligature was carried 
and the broad ligament secured en masse, then over it was passed a pair 
of interlocking forceps by which the broad ligament was constricted, 
preliminary to its being severed, after which the ligament could be ligated 
in sections or the clamp permitted to remain. The other broad ligament 
was treated in a similar manner. The advantage he claimed for this 
procedure was greater security and control of hemorrhage, and that the 
vagina was held at a lower level and its prolapse prevented. The position 
of the patient, with the preliminary dilatation of the anus, gives greater 
freedom of access to the uterus. 

Accidents of Vaginal Total Extirpation. The most frequent injury 
is that of the bladder, which can take place in various ways. Thus, 



PUERPERAL TUMORS. 71I 

it may occur in the blunt separation from the anterior cervical wall. 
The danger of this becomes greater the more closely the new formation 
has approached the bladder. If it has passed over to the external layer 
of the bladder- wall, we may readily puncture or tear the bladder in the 
most careful separation. When the bladder is infiltrated, the preferable 
plan is to cut out the diseased tissue and close the opening by sutures. 
Injury of the bladder is recognized, however, most frequently for the first 
time at a longer or shorter period after the operation, when a part or the 
whole of the urine is lost through the vagina. Either a small bladder 
injury has been overlooked, or, what is probably more frequent, the blad- 
der has not been separated sufficiently from the ligament, and in placing 
the ligatures upon the parametrium a portion of the bladder is fastened in 
the ligature, so that a slough of the affected bladder-wall occurs. A 
spontaneous closure frequently results from the scar retraction. When 
it has not closed, the repair of the fistula must be undertaken by operation. 
Kaltenbach claims that injury of the urinary apparatus occurs in about 
10 per cent, of all cases; this, for the last few years, should be too high. 

An injury of one or both ureters is occasionally observed. The injury 
can be avoided if the bladder and ureters are well pushed back. It does 
not require the previously mentioned sounding of the ureters to avoid 
ureteric injuries. One should exclude cases from operation in which the 
parametrium and the surroundings of the ureter are infiltrated with car- 
cinoma. In such cases the shoving back of the ureter is exceedingly 
difficult, and frequently is associated with injury. The most serious 
injury of the ureter consists in the application of a ligature upon it or upon 
the tissue about it so that it is laterally compressed. Ligation of both 
ureters is, without question, fatal, and the ligation of one manifests con- 
siderable gravity. Schatz does not believe the ligation of one ureter neces- 
sarily unfavorable, as the other kidney performs increased duty. He also 
believes that in one case after ligation of the ureter the canal again be- 
came penetrable a few days later. A number of operators have had to 
remove the corresponding kidney as a result of ligation of the ureter. 
Zweifel, in double-sided ureteric ligation loosened the ligatures on the 
one side, forty-eight hours after the operation, and the strongly swollen 
ureter was made accessible again to the bladder; but as urine retention 
continued six days after the operation, the ligature on the other side was 
removed and the restoration of the ureters attained. 

Injuries of the rectum are less likely to occur. They take place 
in especially unfavorable cases where adhesions exist between the uterus 
and the rectum. Frommel reports a case in which, in an attempt 
to open Douglas' space, the adherent rectum was injured, and, in 
spite of the most carefully introduced sutures, he lost the patient from 
septic peritonitis. In rare cases communication between an intestinal 
loop and the vagina has occurred, with involuntary fecal discharge. 
This is most generally from relapse in the operation scar, in which 
the carcinoma extends upon an adherent loop of intestine. Numbers 
of cases are reported in which ileus has resulted from adhesions in the 
open peritoneal wound. It was my unfortunate experience to have this 



712 GYNECOLOGY. 

occur nine years after the original operation. In symptoms of ileus the 
intestinal loop should be separated from the vagina after reopening the 
wound. In old cases the condition is best treated through an abdominal 
incision. If this fails, an artificial anus should be made or the affected 
loop of intestine should be resected. 

Abdominal Hysterectomy. The first systematic operation for the 
removal of a uterus for malignant disease through an abdominal in- 
cision was performed by W. A. Freund, on the 30th of January, 1878. 
The operation has undergone a number of modifications since his introduc- 
tion of it. After preliminary preparation (§ 124 to § 132) the operation 
is performed as follows : 

1. The patient is placed in the lithotomy position, the friable tissue 
is removed from the cervix with the finger and spoon curet, all loose and 
ragged edges are trimmed with the scissors, the surfaces seared with the 
thermocautery, and the lips sutured to close in all infected tissue. Where 
this cannot otherwise be accomplished, flaps should be dissected. A 
folded piece of gauze is inserted in the vagina with one end protruding 
from the vulva. Before proceeding further, the gloves should be changed 
and the instruments which have been used discarded or resterilized. 

2. The patient is placed in the Trendelenburg posture and an incision 
made in the median line from three centimeters above the symphysis to 
a short distance below the umbilicus, through which the intestines are 
pushed toward the diaphragm and walled off by gauze. 

3. The uterus is secured by a double tenaculum and vulsellum forceps 
or sutures which have been passed through the fundus, drawn up and the 
upper part of each broad ligament clamped, taking care not to include 
the ureter. The round ligament should be secured by a separate clamp 
well toward its outer end. 

4. Cut the broad ligaments internal to the clamps, secure bleeding 
from the uterine side by hemostatic forceps, join the extremities of the 
broad ligament incision by one through the anterior peritoneum above 
the bladder, and strip it and the bladder away from the cervix and 
broad ligament. 

5. Spread out the broad ligament so as to expose the ureter. Push 
the finger along its course under the uterine artery which should be 
either clamped or ligated and cut. 

6. Clamp and cut the uterosacral ligaments; make sure that all 
bleeding vessels are secured. Have an attendant withdraw the gauze 
from the vagina. Place a pair of large angular forceps upon either side 
of the vagina below the cervix and sever it below them. The surfaces 
are thus protected from being soiled or contaminated from the cervix and 
the removal of a good portion of the vagina ensured. 

7. The clamped vessels are ligated with chromic catgut ligature, 
exercising care not to include nor pinch the ureter. 

8. Extend the peritoneal incisions to permit the inspection and re- 
moval of enlarged lymphatic glands from the bifurcation of the aorta 
to the obturator foramen. Secure all bleeding vessels. Pack the surface 
above the vagina loosely with iodoform gauze and stitch the peritoneal 



PUERPEILA.L TUMORS. 713 

surfaces over it with continuous chromic catgut sutures, inverting all 
ligated stumps into the vagina. 

9. Remove all gauze pads, cleanse the pelvis, and close the abdominal 
wound in such a manner as to retain analogous structures in apposition. 
(§ 148.) Cleanse, and apply dressing. Where the conditions make it 
desirable, after stripping back the anterior peritoneum and bladder the 
broad ligament can be spread out, the uterine artery traced outward 
and ligated near its source, the ureters raised, held to one side by traction 
ligatures, and a much larger portion of the parametrium removed. 
Where the ends of the ureters are imbedded in carcinomatous material, 
it may be necessary to resect them in order to remove all the affected 
tissue, when they should be re-inserted into the bladder. 

The gauze inserted in the pelvis is withdrawn through the vagina in 
four to six days. 

In Freund's first procedure the broad ligaments were ligated external 
to the appendages, a second ligature was placed on the portion of the 
broad ligament which included the round ligament, and a third secured the 
base of the broad ligament by being introduced from the vagina through 
a trocar needle which Freund devised for the purpose. The last liga- 
ture was tied upon the base of the ligament as firmly as possible. In 
this way three ligatures were inserted, one under another. The other 
broad ligament was secured in the same manner. The peritoneum above 
the bladder fundus was cut transversely upon the anterior uterine wall. 
A similar section was made upon the posterior wall, somewhat lower, 
and these wound margins were united with a silk loop after the removal 
of the uterus. The uterus was separated by knife or scissors. Hemor- 
rhage from small vaginal arteries was controlled by ligation. All the liga- 
tures were carried into the vagina, and by traction the stump was drawn 
down. This dragging made the peritoneum of the bladder approach 
that of the posterior wall of the pouch of Douglas. These two walls 
could be united by continuous catgut suture. A most careful toilet of 
the peritoneum was accomplished, the eventrated intestines were returned, 
and the belly wound closed with sutures. The sutures that were pushed 
into the vagina could be removed by traction at the end of three weeks. 
The greatest danger of the operation was infection of the peritoneal cavity. 

This operation has undergone many modifications. Crede proposed 
to resect a part of the anterior pelvic wall several days before the operation, 
but found no imitators. A. Martin made a moon-shaped abdominal 
incision from the one anterior superior spine to the other, by which he 
hoped to be able to keep the intestines better in the abdominal cavity. 
He has not continued the procedure. The separation of the bladder from 
the uterus prior to the introduction of the base sutures has been a great 
improvement, decreasing the danger of injury of the bladder and of liga- 
tion of the ureters. Kuhn raised the uterus by means of a colpeurynter 
in the vagina, and made it more accessible. Eastman accomplished 
the same thing by a grooved staff through the posterior vaginal fornix. 
Bardenheuer advocates leaving open the peritoneal wound for drainage, 
but his results were not such as to make the plan acceptable. 



714 GYNECOLOGY. 

A modification of the operation is to make an incision through the 
vagina around the cervix; pack the cavity with iodoform gauze and com- 
plete the operation from above. Another is: to separate the front and 
back, open into the vagina, and complete the operation by the appHcation 
of clamps to the broad ligament. Veit operated by ligating and cutting the 
broad ligaments as far as the vault of the vagina; then he completed the 
operation through the vagina. Gubarroff, of Moscow, advocates the 
abdominal procedure because of the impossibiUty of the removal of 
lymph-glands and the tissue at the base of the broad ligament in vaginal 
total extirpation. 

In marked involvement of the cervix Rumpf proceeded by the follow- 
ing plan: He ligated the broad ligament above, opened the parametrial 
connective tissue, and proceeded to expose each ureter in its entire course 
from the psoas muscle to the bladder; thereby the uterine arteries were 
severed and ligated, and the parametrial tissue could be removed bluntly 
nearly to the uterus without incidental bleeding. Subsequently the anterior 
leaflet of the broad ligament was cut through, the peritoneum over the 
surface of the bladder divided transversely, and the latter bluntly separated 
from the cervix. The parametrial tissue beneath the ureter could be re- 
moved still further. The vagina was separated by means of a Paquelin 
cautery, after the removal of the uterus, was filled with iodoform gauze, 
and the peritoneum was closed over the rest of the broad ligament. 
Rumpf reports a case operated upon in this manner which remained free 
from relapse for over two years. Clark and Kelly effected the same 
purpose by introducing fine bougies into the ureters to render them 
perceptible. 

Ries advocates the removal of the lymphatic glands on account of their 
being the source from which redevelopment occurs. He operates in the 
following manner: 

1. Through the vagina he amputates the portio vaginalis and tampons 
with iodoform gauze. 

2. Through the abdominal incision from the symphysis to the umbilicus 
he ligates the ovarian artery in the infundibulopelvic ligament near the 
pelvic wall, and splits the peritoneum over the common iliac, exposes the 
vessel by blunt and sharp dissection until the bifurcation is exposed, 
when the ureter is separated as far as the bladder. 

3. The broad ligament is ligated toward the pelvis in sections and the 
part toward the uterus is secured with clamps. The bladder is separated 
bluntly from the surrounding broad ligament and the uterine artery tied 
peripherally. 

4. The collected fat tissue with the glands is removed from between 
the large vessels, the external and internal iliac. 

5. The vagina is opened, the uterus removed, and the vaginal canal 
filled with iodoform gauze, while the peritoneal flaps are united with con- 
tinuous silk suture and the belly cavity completely closed. 

When infection is so great as to require such an extensive separation, 
the marked danger from sepsis and from relapse of the disease renders 
the operation of questionable value. Werder, of Pittsburg, in order to 



PUERPERAL TUMORS. 



715 



lessen the danger of wound reinfection, advocated an abdominal hysterec- 
tomy in which, after ligation of the broad ligaments, the bladder is pushed 
off not only from the anterior surface of the uterus, but from the anterior 
portion of the vagina for one-third to one-half its length. The tissues 
also are separated from the vagina posteriorly and laterally, the abdominal 
wound is closed by a previously introduced suture or hooked forceps; 
the uterus then is drawn through the vaginal outlet and the remaining 
portion of the operation completed by the vulva, which saves the wound 
from contact with the infected portion. 

In order to control hemorrhage in an extensive dissection of the pelvic 
structures, Polk advocated ligation of the anterior trunk of the internal 




•: Tube 



Fig. 538. — Ligation of the Anterior Trunk of the Internal Ihac. 

iliac artery. (Fig. 538.) The distribution of vessels from these trunks is, 
however, somewhat irregular, the vessel itself is short, and the structures 
supplied by the posterior trunk are so bountifully nourished by anastomo- 
tic vessels that I have tied one or both the internal iliac vessels, which 
permitted a most extensive dissection free from bleeding. In all of these 
cases the involvement of structures was so extensive that the operation 
was of doubtful utility. The first patient survived the operation and 
returned home, but soon perished from a recurrence, the second case 
developed tetanus at the end of ten days after the operation, and died. 
Schroder, after ligation of the infundibulopelvic ligaments and the 
portion of the broad ligaments containing the uterine arteries, amputated 



7l6 GYNECOLOGY. 

the fundus at about the level of the internal os. After bleeding vessels 
had been secured and the stump dissected out, the vaginal surfaces 
were united, over which the peritoneal flaps were sutured. The op- 
eration is objectionable because of the danger of reimplantation. 
Mackenrodt urges not only the removal of the glands of the pelvis, but 
also an extensive removal of the parametric tissue, since in the latter 
metastatic nests were most frequently found, which were the chief cause 
of recurrence. In order to accomplish this most effectively, he advocates 
the following procedure : 

1. A large crescentic abdominal incision from one iliac spine to the sym- 
physis and upward to the opposite is made, through which insertions 
of the recti muscles are divided without opening the peritoneum, and the 
abdominal muscles are separated from the pelvic attachments. 

2. The peritoneum is pushed off to its reflection over the anterior 
wall of the bladder, when it is cut through and pushed behind the 
uterus. 

3. The uterus is drawn out and the ovarian arteries ligated in the 
usual manner. The peritoneum is then sutured behind the uterus, from 
the right side of the pelvis across to the left, covering the sigmoid flexure, 
which permits the subsequent steps to be extraperitoneal. 

4. The pelvic peritoneum is dissected up as high as the iliac vessels, 
where the glands are found and removed with fat and connective tissue. 
During this stage the ureters are carefully protected. 

5. The bladder and rectum are separated, the entire vagina freed. 

6. The broad ligaments and paravaginal tissues dissected out, the 
vagina clamped and divided with cautery below the clamps. 

7. The space between the bladder and the abdominal wall is drained 
through the lower angle of the external wound. The divided recti are 
united by silver wire sutures and the abdominal wound closed. Usually 
considerable suppuration is expected between the bladder and the rectum. 
In none of the cases thus treated has the absence of recurrence been 
sufficiently long to make the performance of so extensive an operation 
seem justifiable. 

Wertheim, Kronig, Kundrat, and von Rosthorn are earnest in their 
advocacy of the removal of the parametrium and lymph-glands in all 
cases of carcinoma. While I would agree with them as to the importance 
of getting well beyond the disease, in the removal of a large portion of the 
parametrium and of the vagina, my experience leads me to believe that 
the attempt to remove the glands is of little avail, as it is impossible for 
the most skilful surgeon to remove all the glands, and the investigations 
of Schauta seem to indicate that the inaccessible lumbar glands are 
frequently infected before those in close relation with the uterus. Fortu- 
nately, the involvement of glands does not always indicate that these struc- 
tures will be the cause of recurrence when the original source of the dis- 
ease has been removed. In the great majority of the cases coming under 
my observation recurrence has followed in the vagina and cicatrix rather 
than in the pelvic glands. When the increased mortality incident to the 
prolonged operation, the tedious convalescence, the aggravated suffering 



PUERPERAL TUMORS. 717 

from ureteral and vesical complications are considered, it becomes 
a serious question whether anything is gained by the extensive and more 
thorough procedure. Wertheim, the apostle of this procedure, had 
an immediate mortality of 12 in the first thirty cases, 5 in the second, 
and 3 in the third series of thirty. Even the latter, [which equals 10 
per cent., is a much larger mortality than men of equal experience usually 
have in ordinary hysterectomy. 

Comparative Advantages of the Two Proceedings. The principal 
danger of the abdominal procedure arises from septic infection. The 
investigations of Menge and others have demonstrated the presence of 
pyogenic germs in the discharges of uterine cancer. The much longer 
duration of the operation, the increased exposure to infection, and the 
lessened powers of resistance favor its development. In the vaginal 
procedure the peritoneum is less exposed to infection, and the operation 
can proceed without any, or with scarcely any, soiling of the peritoneal 
cavity. In our present methods of procedure the operation is more ex 
peditious; with the separation of the bladder from the cervix and the 
broad ligament the uterine artery can be ligated without danger to the 
ureter. 

If the abdominal procedure afforded no greater advantage than 
the extirpation of the lymphatic glands it would be of little significance 
when it is remembered that the glands are rarely involved until late in 
the disease; and when the disease has extended to the lymphatic glands of 
the pelvis, the operation is little better than a mutilation, for it will scarcely 
have any influence upon the subsequent progress of the disease. 

Notwithstanding the vaginal operation can be done much more 
expeditiously and with less danger to the patient, with less discomfort 
during the convalescence, it cannot be denied that in cancer of the uterus, 
where the disease is confined to that organ, the abdominal operation 
should be preferred. This preference is granted it not because it permits 
us to extirpate the lymphatic glands — for I believe that no operator is 
sufficiently skilled to make sure that all the lymphatic glands are removed, 
and even if they were, the extensive lymphatic system would still afford 
opportunities for the retention of infection — but because it enables the 
operator to remove a larger amount of parametrial tissue with greater safety. 
The large number of cases in which vaginal hysterectomy has resulted fa- 
vorably, the fact that where recurrence takes place it is in the cicatrix, 
in the vaginal wall, or in the parametric tissue, leads me to believe that 
the assertion regarding the infrequency or lateness of lymphatic gland 
infection is correct, and that where the disease has resulted in the involve- 
ment of the glands, no operation affords much hope of cure. In cases 
in which it is evident that the disease has extended outside the uterus and 
the operation is done for its palliative effect, removing only the infected 
tissue, the abdominal procedure should be preferred, as it enables the 
ureters and bladder to be kept under observation better. 

A narrow contracted vagina, a large or fixed uterus, extensive involve- 
ment and destruction of the cervical walls, which afford no firm tissue to 
be seized, and more or less fixation of the uterus from inflammatory 



7l8 GYNECOLOGY. 

lesions, render the vaginal procedure very difficult. Complications of 
the diseased uterus with abdominal growths, such as myoma, ovarian 
tumors, and extra-uterine pregnancy, should be attacked through the 
abdopien. When we come to the duration of after-results, the advantage 
seems to favor the abdominal procedure. 

Injuries of the ureters occur less frequently by the abdominal route, 
but in all cases of extensive involvement of the parametrium, the operator 
should ascertain the position of the ureter by following it down from above 
before blindly applying a ligature. Through neglect of this precaution 
I have thrice ligated a ureter. In one of these cases the patient had no 
urine enter the bladder for two days, when I reopened the abdomen to 
find the ureters severed and tied. They were implanted into the blad- 
der. The patient recovered and lived nearly a year when she succumbed 
to a recurrence of the cancer. If the ureter is unavoidably or accidentally 
injured, an attempt may be made to unite it by suture, as was done by 
von Tauffer and Westermark, or the ureter may be implanted in the blad- 
der. 

In extensive parametrial involvement, where the infiltrate surrounds 
the uterus, I have in several cases purposely cut through one or both 
ureters, dissected out the involved structure to the pelvic wall, and rein- 
serted the ureter into the bladder at a higher level. In all of these patients 
the ureter was distended to the size of a finger as a result of compression 
from the infiltrate. All recovered from the operation, but four suc- 
cumbed some months later to recurrence of the disease. Kustner, when 
unable to accomplish a vesical transplantation, formed a vesicovaginal 
fistula, followed later by a colpocleisis in preference to a nephrectomy. 
Where the ureter has had to be resected and is too short for reinsertion 
into the bladder, it may be brought out through the loin on the back, or 
the pelvis of the kidney may be opened and drained as advised by Watson. 

The Sacral Method. Kraske, in 1885, introduced an operative pro- 
cedure, under the title of the sacral method, for the purpose of extirpating 
the upper part of the rectum for carcinoma. It consisted in resecting the 
rectum after the removal of the coccyx and a portion of the sacrum. 
Hochenegg, in 1888, after a series of brilHant successes, adapted the 
operation to the treatment of some of the disorders of the female sexual 
organs, and the following year reported the application of the method to 
the removal of the uterus. The operation was performed as follows: 
The patient was placed in the Sims position, with the pelvis slightly 
elevated, an incision was made from two to three centimeters above the 
right sacro-iliac synchondrosis to within one centimeter of the left side 
of the anus. After cutting through the skin and fascia, the under part of 
the sacrum and the entire coccyx were exposed. Now follows the bone 
operation. If the coccyx is large and broad, its removal is sufficient; 
otherwise a portion of the left sacral wing is also resected. If a part of 
the sacrum is to be removed, we cut through the sacrosciatic ligaments, 
and with a rongeur cut away the left side of the lower two segments of the 
sacrum. The prevertebral fascia is split the entire length of the wound; 
the now free-lying rectum is bluntly separated on the left side and dis- 



PUERPERAL TUMORS. 



719 



placed to the right. Later experience demonstrated the advisability of 
opening upon that side of the rectum on which the parametrium was most 
infiltrated. The rectum is shoved aside, and Douglas' space opened by a 
transverse incision, which is recognized as the hardest part of the operation. 
One or two fingers are introduced into the opening, the uterus and its 
appendages are explored, and the practicability of their removal is 
determined. 

In removal of the uterus it is seized and drawn through the incision 
of Douglas' space into a position of strong retroflexion. The broad 




Fig. 539. — Skin Incision for Sacral Resection. 

ligaments upon both sides are cut between double ligatures; when the 
uterus becomes so movable that it can be drawn further down, its anterior 
surface is inspected. The peritoneum above the vesico-uterine reflexion 
is cut transversely, and, together with the bladder, pushed downward. 
The uterine arteries are generally ligated under the eye, and the ureters 
easily pushed aside, although they have been injured. After the separa- 
tion of the lateral appendages the organ remains in union only with the 
vagina. A transverse incision through the peritoneum in front of the 
uterus is made. This is separated and sewed to the peritoneum of the 
anterior wall of the rectum. The vagina is closed in two stages. lodo- 



720 



GYNECOLOGY. 



form gauze is packed about the remaining portion of the wound and 
brought out at the center of the posterior wound, both ends of which 
have been closed. This operation was extended by Herzfeld, who found 
that, in the majority of cases, only the removal of the coccyx was required. 
He penetrated the structures to the right side of the rectum, for the 
reason that the vagina is situated more to the right, is more accessible, 
and there is less interference with the rectum. The transverse opening is 
made in Douglas' space, the right and left broad ligaments are tied and 
cut, after which follows a complete closure of the peritoneum before 




540. — Sacrum Resected; Rectum Exposed. 



further extirpation. There is no possibility of soiling the peritoneal cavity 
by contact with cancer. The rectal peritoneal surface is sewed to that of 
the bladder, and the stumps are fastened in the wound laterally, making 
them extraperitoneal. Hegar cut transversely in the anterior uterine 
wall above the bladder fundus, and shoved back the bladder and ureters. 
The subsequent removal of the uterus is similar to that described in Hoch- 
enegg and Herzfeld's operg,tion. Schede protests earnestly against sac- 
rificing the sacrum. In a large series of operations he never found it 
necessary to remove enough of the sacrum to involve the lower sacral 



PUERPERAL TUMORS. 



721 



foramen and its nerve. He designates the removal of the lower two 
sacral nerves a crime, as the destruction of these nerves paralyzes the 
detrusor vesica uterini and causes a very severe inflammation of the blad- 
der, which increases the distress and peril of the patient. Zuckerkandl 
introduced a still more conservative method, in which there was no bone 
resection. • Skin section was from the left side of the right tuberosity 
of the ilium until midway between the end of the coccyx and the anus. 
At the sacral margin it formed a bow bent hard to the right. The gluteus 
maximus muscle, the sacro-iliac and sacrosciatic ligaments, the musculus 




Fig. 541. — Rectum Pushed Aside; Uterus Exposed. 

coccygeus, and part of the levator ani muscle were cut through at the 
margin of the sacrum and coccyx. The rectum is set free and the opera- 
tion proceeds as previously described. 

Wolffler places the skin section to the right of the sacrum, over the 
somewhat narrowed part at the union of the coccyx and sacrum; the 
section forms an easy curve, with its concavity to the right, and ends 
near the rectum, in the neighborhood of the vulvar commissure. The 
gluteus maximus and the levator ani are cut near the rectum, and the 
deeper structures become accessible. Zuckerkandl designated his and 
46 



722 GYNECOLOGY. 

Wolffler's methods as parasacral section. These operations are more 
bloody, because the sacral, the median, and the inferior hemorrhoidal 
arteries and the pudendal artery and vein are in the range of the incision. 
Hegar made an osteoplastic resection of the sacrum and coccyx. A 
V-like incision, with the arms beginning one centimeter beneath each 
inferior posterior iliac spine, converged to the point of the coccyx. After 
separation of the soft parts and bands near the sacral margin the rectum 
was bluntly separated from the anterior sacral surface, a chain-saw 
was introduced between the third and fourth sacral openings, the sacrum 
cut transversely through to the posterior periosteum, which was retained, 
and the sacral part turned up. After the operation this flap was returned 
to place and secured by sutures. Consolidation usually took, place in a 
very short time. In two cases necrosis resulted, and the flap had to be 
removed. After the operation the skin wound was closed, with the ex- 
ception of a small drainage opening, and the advantage of the procedure 
is that the anatomic relations are exhibited as before. This osteoplastic 
resection of the sacrum is applicable to the removal of carcinomatous 
uteri as well as retro-uterine tumors. 

Kocher and Heinecke recommend the splitting of the lower sacrum 
in the middle and the separation of the sides from one another. Levy 
and Schlange, in opposition to Hegar, turned the flap toward the anus, 
while Rydygier made the incision in the soft parts on one side, and, 
aftei* transverse incision, turned the sacrum toward the other side. 

Borelius changed this method in the removal of a carcinomatous 
uterus as follows: He began with the skin section in the middle line, 
about two centimeters above the sacrococcygeal articulation; then some- 
what to the left, approached the point of the coccyx forward, through 
the rectosciatic fossa, three to four centimeters from the anal aperture; 
from this point he progressed forward, and again approached the middle 
line until led to the posterior commissure. After laying free the left 
border of the coccyx, the sacrococcygeal angle is cut through. The skin 
section, in its entire length, is sufficiently deepened, and the coccyx, to- 
gether with the anal portion, is held to the right; after separation of the 
rectum we can proceed from the posterior vaginal wall to the extirpation 
of the sexual organs. After the operation the coccyx is replaced and 
fixed with periosteal sutures. 

Various modifications of Hochenegg's procedure for the extirpation 
of the uterus have been introduced; by proceeding, as Herzfeld suggested, 
to the right of the rectum, Douglas' space will not be missed. In the 
search for the space — made easy by having an assistant introduce the 
finger into the rectum to indicate the plica transversalis recti, as the cup 
of Douglas' space always lies at the height of this fold — we only need to 
make the incision to enter the space. The difficulty in finding Douglas' 
space has occasioned the majority of operators to renounce the primary 
opening in the peritoneal cavity entirely, and to proceed to the extirpation 
of the uterus by the opening from the vagina. 

Incidentally an easy way of accomplishing the uterine extirpation 
would be to follow the proceeding of Czerny, who cuts from the vagina 



PUERPERAL TUMORS. 



723 



about the portio in the same manner and separates the structures as 
in the vaginal method. After completion of the operation most 
operators fill out a wound nearly the size of a fist with iodoform gauze 
and treat it as an open wound, with the exception that the wound in the 
skin is partly closed, leaving an opening in the center, through which the 
iodoform gauze is carried out; also, in the osteoplastic resection we can- 
not well renounce the use of this drain, and iodoform gauze is placed on 
each side. Steinthal brought the gauze out through the vagina, and thus 




Fig. 542. — Patient From Whom Uterus, Ovaries, Posterior Wall of Vagina, Perineum, and 

Five Inches of the Rectum Have Been Removed. 

A. Artificial anus. B. Anterior wall of Vagina. C. Vulva. 

closed the entire posterior wound. Zweifel, Schauta, and Wertheim have 
operated in a similar manner with favorable results. One objection to 
this operation is the long convalescence, requiring fully six weeks for the 
patient to recover, after which time necrosis of the bone may cause fistu- 
lous openings, which may continue for a much longer period. The 
osteoplastic resection seems to shorten the convalescence. The com- 
plete suturing of the sacral wound, with drainage through the vagina, 
is the most satisfactory procedure. It can be claimed for the procedure 



724 GYNECOLOGY. 

that the entire operation can be accomplished more readily under the eye, 
and ligation of the uterine arteries is accomplished separately, and not 
by mass ligature. Injuries of the ureters are easy to avoid. Such 
injuries, however, do occur. 

The operation may be found advisable in cases in which ther e is reason 
to suppose that the ureter is embedded in infiltration. In one case 
Schede resected a piece of the bladder three centimeters long, together 
with a long piece of the ureter. Von Winckel objects to the operation 
on the ground that he could not see the ureters. Hochenegg reported 
ninety-eight, with eighteen fatal cases — eight of sepsis or pelvic phleg- 
mon. The loss of blood is much greater than in the vaginal operation. 
In the course of the after-treatment life may be endangered by bursting 
of the peritoneal wound. Hochenegg points out that, by reason of the 
sacral method, a large series of cases of carcinomata of the bladder are 
reported ; the ureter and parametrium have become more or less involved 
and increase the technical difficulties that complicate the operation. 
I have removed the uterus, ovaries, and tubes by sacral resection in one 
case without injuring the rectum, and in two with resection of the rec- 
tum. All these recovered. In one of the latter the operation con- 
sisted in the removal of five inches of the rectum, the uterus, ovar- 
ies, and tubes, the posterior wall of the vagina, and the perineum. 
The rectum was stitched to the skin over the sacrum and to the anterior 
wall of the vagina. This operation was performed for epithelioma in- 
volving the rectum, extending to the perineal margin around the anus, 
and in the parametrial tissue behind the uterus. The patient had pre- 
viously undergone a Maydl colostomy. After the recovery of the posterior 
wound an incision was made around the artificial anus and the two ends 
of the bowel were raised and reunited, after which all fecal discharges took 
place through the sacral anus. Thirteen months after the operation the 
patient returned to her home in Ireland, since which time no knowledge 
has been obtained of her progress. 

The Perineal Method. Zuckerkandl, in the year 1889, presented a 
method for extirpation of the uterus by an opening between the vagina 
and rectum. With the patient in the lithotomy position, the intestine 
was raised toward the sacrum with a / \-shaped flap incision, 
whose nearly seven centimeters long transverse portion lies in the half 
oval line in front of the rectum, and whose angles upon each side extend 
to the ischial tuberosities. After separation of the skin and super- 
ficial fascia, and separation of the skin-flaps from the under layer, the 
projecting bundle of the external sphincter, which penetrates the labial 
commissure, is separated and the lower part of the vagina loosened from 
the rectum. The remaining part of the septum is bluntly dissected until 
Douglas' fold is reached, when the vagina is opened transversely, the 
uterus drawn out from behind, and its extirpation occurs as readily as in 
the sacral method. The peritoneum is closed, and, after removal of the 
uterus, the ligament stumps can be buried in the peritoneal cavity or 
placed by sutures extraperitoneally, as in the vaginal method. Frommel 
seems to be the only one who has found this operation practicable. He 



PUERPERAL TUMORS. 725 

holds it advantageous to cut about the vagina, as in the vaginal 
method, push back the bladder, pack the vagina with iodoform gauze, 
and then perform the perineal operation. The operation is quite 
bloody, as the numerous venous plexuses between the vagina and rectum 
are opened. The operation seems an unnecessary interference with 
the pelvic floor, as the same increased room will be secured by enlarging 
the vagina and the danger from infection necessarily must be increased 
very greatly. 

The Mortality of Abdominal and Vaginal Operations. The operative 
mortality necessarily must be governed by the percentage of carcinoma- 
tous cases submitted to operation. The surgeon, who finds but 20 per 
cent, of his cases operable, accepts less risk than the one who operates 50 
or 60 per cent. Thus, in a Berlin clinic, out of 402 carcinoma cases, but 
d>7^ were found operable. Wertheim, in his first series, operated but 
29 per cent., while in the last, 51 per cent, were operable. The mor- 
tality may be influenced also by the character of the operation. The 
radical procedure, which aims to remove the parametrial tissue and the 
infected glands, necessarily must be attended with a large mortality. 
Wertheim had from 10 to 40 per cent, respectively in his last and first 
series. The mortality may be fixed at 6 to 10 per cent, for abdominal 
hysterectomy where ordinary care is exercised to remove the adjacent 
parametrium without reference to the glands, and from 3 to 5 per cent, 
for the vaginal procedure. 

Duration of Recovery. In the earlier operative work it was considered 
that if a patient survived the operation two or three years without recur- 
rence, she might be pronounced cured, but further experience has de- 
monstrated that recurrence may take place up to the fifth year. After 
this lapse of time the probability of permanent recovery is great. There 
are occasional cases in which recurrence after partial operation has been 
discovered as late as six, seven, or eight years. It would be a question in 
these cases, however, whether it might not be considered a condition 
similar to that which would take place in a woman whose susceptibility 
to malignant degeneration was great, and that the irritation produced in 
scar tissue would favor such development and should be considered a 
primary, rather than a secondary, condition. Frommel, in his investiga- 
tions, has never seen recurrence follow after four years. In one hun- 
dred and eighty-eight cases of cancer of the neck and twenty-six cases of 
cancer of the body reported by Fritsch, he saw sixty-five free of recur- 
rence at the end of one year, or 58.5 per cent, of the cases in the neck 
and 69.2 per cent, of those in the body. At the end of two years 
Olshausen saw one hundred and forty-one, or 44.7 per cent., of the 
neck, and sixteen, or 81.2 per cent., of the body, free from recurrence; 
at the end of three years he reported one hundred and twelve or 37.5 
per cent., of the neck, and thirteen, or 69.2 per cent., of the body. At 
the end of four years he found free from recurrence of cancer of the 
neck eighty-eight, or 29.5 per cent.; of the body, eleven, or 63.6 per cent. 
From this collection it is evident that in the first and second years after 
operation the great majority of recurrences appear, and then the num- 



726 GYNECOLOGY. 

ber falls off more and more. The duration of life following an operation 
largely depends upon the stage of advancement of the disease. Leopold 
is quoted by Williams as having recorded a recurrence of 23.7 per cent, 
in early cases as contrasted with 66 per cent, in a more advanced stage. 

The final results of individual operators, however, are so very different 
that it is impossible to draw valuable conclusions from them. Thus, 
Kaltenbach, with his brilliant primary operative results, evidently ex- 
tends the indications for the operation quite far, and subjects all cases to it 
in which it seems technically possible. In such a large number of cases 
there must be a few in whom the new formation has advanced propor- 
tionately far, and relapse is not surprising. Leopold, on the other hand, 
drew the indications very narrowly. Statistics demonstrate that the 
vaginal operation has given excellent primary results, but, on the other 
hand, show that, of all the radical operations to which patients are sub- 
mitted, after a year recurrence has followed in one-half, and in the second 
year in a still considerable percentage. The gravity of the disease can 
be appreciated still further when we realize that only a small percentage 
of the cases which come under the observation of the gynecologist are in a 
condition to permit of radical operation. 

Recurrence. These cases subjected to radical operation when the 
parametrium without doubt is infiltrated extensively, are not followed 
immediately by recurrence only, but the fatal termination also is very 
rapid. Tannen has proved that the duration of life in such recurrence of 
cancer is briefer than it would have been had the disease been let alone, 
for eight or nine months of life for patients in whom the disease thus 
recurs is less than would be secured by such palliative treatment as partial 
resection or energetic cauterization of the diseased area. Sanger and 
Thorn have shown that life is lengthened by the latter. Surgeons, from 
their experience in mammary cancer, are inclined to combat these views, 
but statistics do not support them. As contra-indications, then, against 
total extirpation are to be considered great enlargement of the uterus and 
extensive adhesions, especially with intestine. Those uteri should be 
excluded from vaginal operation which cannot be removed through 
the vagina without morcellation. To this class belong carcinomata 
complicated with myomata. Pregnant and puerperal uteri are propor- 
tionately easy to remove by the vagina, in spite of their enlargement, 
as has been demonstrated by Olshausen, Hofmeier, and others, and the 
comparative narrowing of the vagina observed in the nullipara and in 
old women exhibits no contra-indications to the vaginal operation. 

The primary operations are so satisfactory that we could scarcely 
wish them otherwise. Olshausen's one hundred total extirpations with 
but one death, when some of the patients were already pyemic, are 
positively brilliant results. Winter describes three forms of recurrence: 
I. Local, or recurrence in the wound — a return of the cancer in its pri- 
mary kind within the compass of the field of operation; 2. lymph-gland re- 
currence — return of the tumor in any lymph-gland of the body; 3. me- 
tastatic recurrence. Dissemination by the blood-vessels leads to the de- 
velopment of the tumor in the more internal organs. The first is produced 



PUERPERAL TUMORS. 727 

either by portions of carcinomatous growth overlooked in the operation 
or fragments that have broken off and lodged in the folds of the wound. 
These correspond more or less to the neighborhood of the previous opera- 
tion, which demonstrates the correctness of Thiersch's view, confirmed 
by Heidenhain's investigation on mammary cancer, that the carcinoma 
frequently extended itself far over the lateral or immediate limits in small 
sprigs, and that, after the removal of the new formation, the mass is seen 
to be separated by healthy tissue from visible sprigs or microscopic cancer- 
nests that may be the source from which the cancer redevelops. 

Our study of the progress of the disease has already illustrated the 
extension of carcinoma of the vaginal cervix into the vault and parametrial 
connective tissue. Mackenrodt and Leopold, in their anatomic investiga- 
tions of extirpated parts of the parametrium, have demonstrated fine, 
microscopically perceptible sprigs situated in remote parts of the para- 
metrium, and it is quite possible that such fine sprigs may be found out- 
side of the incision as well. It is, consequently, difficult to be certain 
whether wound relapse occurs from sprigs of cancer growth in the para- 
metrium or from small masses which have been broken off from the dis- 
eased tissue and been implanted upon the new wound. Most generally 
the patient gains in body-weight and improves in appearance after the 
operation, but individual cases will be found to exhibit pain in the depth 
of the pelvis at an early period, which radiates from the lower extremities, 
and frequently becomes very distressing. In its further course there is 
edematous swelling of the lowxr extremities, often venous thrombosis; 
in other cases, bleeding and discharge, which cause the patients to return 
for investigation, 

The diagnosis of carcinoma recurrence usually is confirmed without 
diffculty if we make a combined investigation from the rectum, with the 
thumb in the vagina, by which the penetrated parametrium can be fixed 
between the finger-tips. Hemorrhage sometimes may take place in 
granulations which are formed about the ligatures, especially if silk has 
been used. When the appendages have been left, a mass that has a 
soft sensation may be felt in the vagina. The cause of bleeding upon an 
exact examination is recognized as the fimbriated end of the tube. I have 
seen periodical bleeding from the vagina after hysterectomy when an 
ovary has been left. The absence of infiltration and the impossibility 
of separating the small tumor masses from a polypus of the vagina con- 
tra-indicate carcinoma. In doubtful cases the tissues should be examined 
with the microscope. 

Another form of recurrence is that of which Winter speaks as infection- 
relapse, in which portions of carcinoma are broken oft\ come in contact 
with healthy tissue, lodge there, and develop the original disease. In a 
single woman upon whom I operated to remove a small uterus through 
the vagina the operation was attended with considerable difficulty; the 
fundus uteri was torn open in attempting to bring it down, and some 
jelly-like material escaped into the peritoneal cavity, which was thoroughly 
irrigated as soon as the operation was completed. Less than six months 
later the patient developed a mass upon the side of the pelvis correspond- 



728 GYNECOLOGY. 

ing to that into which this fluid material had escaped, and, upon opening 
the mass, material similar to that which had escaped from the uterine 
cavity was found. The disease progressed and eventuated in the death 
of the patient. 

The second form of recurrence is a lymphatic gland recurrence. The 
investigations of Poirier and Leopold have demonstrated that the lym- 
phatic vessels of the middle and upper thirds of the vagina and those of 
the cervix proceeded to the iliac glands along the course of the iliac ves- 
sels and at the sacro-iliac articulation in the angle formed by the separa- . 
tion of the external and internal iliac vessels. The lymphatic vessels 
of the uterine body proceed to the upper margin of the broad ligament 
and follow the spermatic artery to the vertebral column, where they open 
into the lower lumbar lymphatic glands, which are situated behind the 
peritoneum in the neighborhood of the large vessels. Fortunately, lymph 
infection occurs late in cancer of the uterus, so that lymphatic gland re- 
currence after total extirpation is a rare condition. After chloroform 
narcosis the roundish, hard, immovable nodules can be recognized in the 
pelvis. 

The third form is that of metastatic recurrence in which the disease 
is carried to more or less distant organs and presents nodules of a his- 
tologic structure similar to that of the primary cancer. These metastases 
in uterine carcinoma are rare, and exist only in advanced stages. 

327. Palliative Operations. Unfortunately, the majority of women 
suffering from cancer of the uterus come under the observation of the 
surgeon too late and must be considered incurable. Extirpation of the 
uterus does not make the prognosis more favorable when the disease 
is widely extended. As much can be done through palliation and 
symptomatic therapeusis, which necessarily is an important part of the 
treatment. The treatment of this large division has failed to receive 
the consideration given to the curable class, but its value must not be 
considered trifling. It comprises not only the study of the means which 
will afford the patient temporary relief, but also those which will diminish 
her suffering and occasionally afford her a ray of hope. The great 
variety of methods advocated betokens the weakness of all efforts to 
oppose the ravages of the fearful disease. 

The principal indication for treatment in incurable carcinoma of 
the uterus is to combat such symptoms as hemorrhage, discharge, and 
pain. Hemorrhage indicates that the new formation of the disease 
projects into the capillaries and small vessels, the walls of which are 
formed by the cancer structure, so that the most trifling injury or increased 
blood pressure results in rupture. The later suppuration results from 
wandering-in of saprophytes, which causes the structure to break down. 
The collection of blood and secretion in the vagina affords ready entrance 
to those germs which cause suppuration. They may invade the surface 
of the less well-nourished new formation. Hemorrhage and discharge 
are not always marked symptoms. The disease often makes great prog- 
ress without these severe symptoms being present. They may be sup- 
planted by a severe seropurulent discharge similar to that which occurs 



PUERPERAL TUMORS. 729 

in senile colpitis, while the odor may be almost completely absent. In 
old women we frequently observe hard, scirrhous forms of cervix cancer, 
which show but trifling inclination to disintegrate; consequently, discharge 
and hemorrhage are wanting, and pain is caused by the further progress 
of the new formation or is exhibited as the only distinct symptom. In 
such cases narcotics almost exclusively become the sheet anchor. 

Cases which require an aggressive treatment are those forms of portio 
and cervix cancer which are especially characterized by vigorous growth 
of the new formation. The more rapid the proliferation, the more rapid 
its transition, and, therefore, the earlier hemorrhage and discharge ap- 
pear. The most effective method of treating rapidly advancing carcinoma 
is the removal of the newly formed mass. In the more gradual develop- 
ment of the disease it progresses deeply; its superficial parts perish 
slowly, often with considerable hemorrhage, loss of fluid as offensive 
discharge, decreased appetite, and associated therewith weariness. Pal- 
liative operative treatment is especially suitable for the cauliflower form 
of growth in the portio, unless the vaginal walls have been extensively 
invaded. Results are less promising when, with existing ulceration, is 
associated very severe infiltration of the pelvic connective tissue surround- 
ing the cervix. Further, when the new formation has already penetrated 
the vaginal structures, the knife should not be employed to do more than 
cut aw^ay the fungiform growth, because the wall is thin and the infiltra- 
tion zone often is difficult to recognize. The knife is especially improper 
in cancer of the cervix when the infiltration has extended to a marked 
degree into the parametrium. In such cases, the sharp curet should find 
employment. The operation should be preceded by careful examination 
under an anesthetic, which is often necessary to determine contra-indica- 
tions to total extirpation. The investigator should observe the extent 
to which the new formation projects into the retro-uterine culdesac or 
upon the bladder wall, for injury to such structures occurs easily, although 
the rectum rarely is injured. 

Approach of the disease to the bladder is best investigated by the intro- 
duction of a catheter, by which the bladder is pressed against the palpat- 
ing finger. The extension to Douglas' pouch is recognized easily by a 
digital investigation through the rectum. In large carcinomatous col- 
lections it is important to ascertain how far the cancer extends beyond 
the uterus. When the parametrium is invaded, preparation must be 
made for severe hemorrhage, as cureting can easily injure the large 
branches of the uterine artery. 

Cureting is the principal palliative operation for cancer, but the 
treatment should not be confined to the use of the curet alone. Such 
treatment injures previously uninvolved tissue, which becomes a favor- 
able soil for the extension of the disease, and the subsequent progress is 
more rapid. Cureting should always be followed by an immediate em- 
ployment of the cautery or by the application of some strong caustic agent 
which will destroy a large part of the infiltrated zone and reach tissue of 
a more normal character. The uterus is exposed by a speculum and 
lateral retractors. In the employment of the cautery the operator should 



730 GYNECOLOGY. 

be prepared to protect the vagina and external genitalia with wooden re- 
tractors. To avoid too much absorption of light from the depth of the 
cavity by their dark color, their inner surfaces should be coated with a 
thin layer of quicksilver. In addition are needed sharp curets, scissors, 
forceps, needle-holder, and needles, the latter for use in case of fistula, 
though they are seldom required. We should also have ice- water for 
irrigation, and sponges or pads or, still better, cotton or gauze pads upon 
long forceps. Although the use of the curet is not painful, it is advisable 
for the patient to be under an anesthetic, as the fear of burning would 
be so great that an effectual application of the hot iron could not be made. 

While the patient may not ask the character of the disease, her fears 
cause her to anticipate the worst, and her confidence in what is being 
done for her will depend upon the apparent gravity of the disease, and the 
abatement of the symptoms which follows the procedure permits her to 
secure new courage. It is well to assure her that we do not expect to 
remove the discharge completely, and that subsequent treatment may be 
necessary. She is thus saved from utter despair upon the return of the 
discharge. 

The procedure is as follows: The patient, narcotized, is placed upon 
an operating table and the parts are cleansed as thoroughly as the con- 
dition will permit; the new formation is exposed with retractors and as 
much as possible of the tissue is scraped away with a sharp curet, reach- 
ing the firm infiltration zone. In the softer parts of the cancer the hemor- 
rhage is considerable, but becomes less as the infiltration zone is reached, 
because there the vessels still retain their contractile power. To limit 
the bleeding, then, it is important to proceed rapidly with the curet. 
As we proceed, the scraped masses are removed by irrigation with ice- 
water, or, probably equally effectively, with water at a temperature of 
120° F. The irrigation enables us the better to inspect the operative 
field. The finger must be employed occasionally to judge the progress 
and the amount of resistance, especially of thin points, particularly 
in the posterior vaginal vault and over the bladder; to assure ourselves 
that perforation will not occur, and that the new formation has been suffi- 
ciently removed. A smaller curet can be used to remove further tufts 
in the uterine cavity. Shreds and ragged masses which elude the curet 
are seized with forceps and cut away with scissors, and the bleeding is 
controlled by firm pressure with gauze pledgets. A crater-like cavity is 
formed, which frequently can project into the parametrial tissue. The 
cavity is further cleansed, and hemorrhage is arrested by the use of the 
thermocautery. It has been advised that the thermocautery be followed 
by coating the vaginal walls with vaselin, impregnating the diseased 
structure with alcohol and igniting it, allowing it to burn for one-half 
minute to a minute and a half, but it is difficult to confine the injury 
produced by this procedure to the diseased structure. Where there is a 
disposition to bleed after the application of the cautery, it may be con- 
trolled by injecting with a hypodermic syringe i part of a i : 1000 solution 
of adrenalin chlorid to 4 of distilled water. After the oozing has been 
controlled, the excavated cavity should be packed with cotton saturated in 



PUERPERAL TUMORS. 73 1 

a 40 per cent, solution of formaldehyde. This agent has a caustic action 
and is more particularly selective of the malignant infiltrate. The 
packing must be covered carefully in order to protect the healthy structures 
from contact with the acrid discharge. In the most favorable cases 
cicatrization is produced. With cicatrization the cavity shrinks and is 
much diminished. The action of the Paquelin thermocautery must be 
prolonged to be most effective. It must be removed frequently, because 
blood and shreds of tissue rapidly coat it. The removal is also done to 
permit the tissues to cool, that undue scorching may not occur at unde- 
sirable points. When the hemorrhage is quite profuse, it is important 
to bring the entire cavity at once in contact with the cautery. After the 
hemorrhage is incidentally controlled, we see, here and there, blood trick- 
ling and oozing from small points, which must be resubjected to the 
cautery until the cavity is lined by a thick, dry eschar. Especial care 
must be exercised toward the vaginal margin, for bleeding will continue 
there the longest. 

To secure a deep, dry eschar, we use irrigation with ice-water at 
intervals only in the early part of the treatment; and later withdraw and 
cool the retractors ; or retain them in the vagina and cool with a pad wet 
with ice- water; or, better still, control the oozing with the injections of 
adrenalin. Should these precautions be omitted, the vagina will be 
burned severely in prolonged operations. With the wooden retractors the 
danger of burning is lessened, but the long use of the cautery will require 
an occasional cooling of the cavity. The procedure concluded, the cavity 
should be packed with formalin gauze. 

In properly selected and carefully managed cases the danger of the 
procedure is slight, and it can be accomplished without injury to the 
bladder or the peritoneum. Injuries to the latter are usually not serious. 
The hemorrhage may be considerable, though it is generally controlled 
without difficulty by the methods suggested. A ligature is rarely required, 
for the cautery is competent to control even arterial bleeding. In the rare 
cases of inoperable cancer of the uterine body great prudence must be 
exercised to prevent the cautery from perforating the thin walls. As 
the finger generally can enter the cavity, the weak places can be recognized 
and undue pressure against them avoided. The procedure usually is 
borne with little discomfort. The patient will scarcely complain, unless 
unfortunately an eschar has been made upon the external genitalia. 
This is very painful and soon becomes edematous. 

After the procedure is completed the vulva should be covered with 
vaselin, and, in the most trifling external burning, a pad should be applied, 
which is frequently wet with lead-water and laudanum, or a carbolic- 
acid solution should be applied to the external genitalia. Slight elevation 
of temperature is generally noticed after such operations, but they exert 
no marked influence upon the general condition, and the temperature 
subsides in a few days. 

Parametritis and septic processes are rarely observed. The tampon 
should remain five or six days. The eschar will be found to have sepa- 
rated partly under trifling suppuration, and the cavity will be more or less 



732 GYNECOLOGY. 

diminished. After withdrawal of the tampon the loose-lying tissues are 
removed carefully. The exercise' of force must be avoided, because it 
causes hemorrhage. The cavity is sponged, and we await the complete 
separation of the slough. Treatment after the removal of the eschar is 
directed to securing cicatrization. Olshausen lauds for this purpose 
tincture of iodin. He uses the stronger solution : 

I^. Iodin pur., i part 

Rectified spirits, 8 parts. 

It is applied by a saturated pledget of cotton, which is pressed lightly 
against the cervix. The superfluous portion flows back into the bowl 
of the speculum, from which it may be used over and over. The alcohol 
is an excellent antiseptic. 

The patient should be advised to wear a napkin after the application 
to protect the clothing. The applications are made every two or three 
days until the cavity contracts and becomes clean. In favorable cases 
a watery discharge follows. Sometimes it is tinged with blood. It 
has entirely lost its offensive odor and is so slight that the patient considers 
herself cured. Torggler tampons the vagina with iodoform gauze satu- 
rated with peroxid of hydrogen and permits it to remain for three or four 
days. The surface is scraped with the sharp curet, subjected to the 
thermocautery, and covered for a few minutes with cotton soaked with 
a 40 per cent, solution of formaldehyde. Six to ten days later a slough is 
thrown off, which leaves a dry wound. 

Caustics. Sims followed the use of the curet by an application of zinc 
chlorid solution. Hemorrhage was controlled by absorbent cotton 
pledgets, wet with a solution of persulphate of iron, which were removed 
and followed by others wet with the zinc solution. Van de Warker 
used a 50 per cent, solution of the chlorid of zinc. After the use of the 
curet small pledgets, squeezed from a 50 per cent, solution of zinc chlorid, 
are placed against the diseased surfaces. The healthy tissues are pre- 
viously protected from injury by an ointment of bicarbonate of soda 
in vaselin. These medicated pledgets are so placed as to come in contact 
with the entire diseased surface; a piece of dry absorbent cotton or gauze 
is laid over them, after which the vagina is filled with a wad of cotton wet 
with a saturated solution of bicarbonate of soda. 

The carbonate causes a decomposition of the zinc salt, which renders it 
less irritating to the tissues. The nurse should wear rubber gloves to pre- 
pare the pledgets. Without these precautions the vagina, and especially 
the introitus, would be badly burned; indeed, in spite of every precaution 
the canal frequently is injured seriously. Where the wall is thin, as over 
the bladder, the weaker solution (5vj to f gj) employed by Sims should be 
substituted. Sims left the tampons undisturbed for four or five days, 
unless earlier removal was indicated by elevation of temperature. He 
ascribed to the agent no especial influence upon the cancer beyond its 
active destructive effect, but Van de Warker believed the drug to have 
a special affinity for the cancer tissue, selecting it and leaving the healthy 
tissue. The microscopic investigations of Ehler upon this subject. 



PUERPERAL TUMORS. 733 

however, demonstrate the contrary — that the cancerous tissue is affected 
only superficially, while necrosis of the healthy tissue extends to a con- 
siderable depth. Frankel employs the zinc salt, but previously scorches 
the surface with the thermocautery. He leaves the pledgets in contact 
with the affected surface for twenty-four hours. Great care must be 
exercised in the cases for which this treatment is employed. Should the 
bladder or posterior vaginal wall be infiltrated, or if these parts are 
protected insufficiently, fistulae may form, which greatly aggravate the 
subsequent condition of the patient. A slough resulting from the appli- 
cation may open the bladder, rectum, or peritoneal cavity. During or 
following the separation of the slough, a hemorrhage so severe as to cause 
a fatal result may readily occur. When the slough has separated, ex- 
uberant granulations develop, and later strong cicatricial contraction and 
shrinking, which Fritsch indicated as the cause of extraordinarily severe 
pain, which is aggravated by the increased infiltration above the scar 
tissue. 

Ricard relates the history of a patient in whom hematometra and 
hematosalpinx followed the introduction of zinc chlorid pencils into the 
uterus. The scar tissue was so dense that the collection could not be 
reached per vaginam, and the woman perished from hemorrhage after 
laparotomy. The cervix and the greater part of the uterus had degen- 
erated in cancer. Many patients in whom this treatment has been em- 
ployed have been so much improved as to justify fully its practice in 
similar cases, but strong solutions and the paste should be interdicted 
absolutely. 

Fraipont advocates the use of liquor ferri sesqui chloridi, from which he 
obtained excellent results. This agent has a superficial action upon the 
surfaces to which it is applied, and forms a slough, following the discharge 
of which hemorrhage is likely to recur. The bleeding following the curet- 
ment can be controlled only incompletely by pressure with an iron solution. 
A better application is a tampon of iron chlorid. Cotton is saturated 
with this substance and packed against the surface. These pledgets 
of cotton form hard lumps, which are difficult to move, and are sepa- 
rated slowly only under strong suppuration • or discharge. An early 
attempt at their removal is attended with severe pain and hemorrhage. 

Leopold advocates the use of a concentrated carbolic acid treatment 
which he continues from one to two months. After radical scraping and 
scorching with Paquelin's cautery he follows it by cureting the surface 
every three months and plunging the cautery into the new-growths so that 
the tissue is rapidly scorched. Chrobak used, after cureting, repeated 
cauterization with nitric acid. Out of sixty-five cases so treated, he at- 
tained good duration results. In one of these cases, after radical sloughing 
of the carcinoma of the cervix three years and nine months later, because 
of the strong scar tissue, there had formed a hematometra which was 
emptied twice. In other cases after repeated cureting and cauterization 
strong scar formation was seen at the end of three years without recurrence. 
The third patient was still alive five years after operation, free from 
recurrence. 



734 GYNECOLOGY. 

This treatment does not seem to have stood the test of time, and now 
is scarcely considered. Goodell advocated in incurable cancer the use of 
applications of powdered pepsin and salicylic acid — pepsin to digest and 
eat off the diseased tissues, salicylic acid to prevent decomposition. 
Cucca and Ungara advocate tampons wet with : 

I^. Methyl-blue, gr. xc. 

Alcohol (95 per cent.). 

Glycerin, aa f 3iij- 

Water, f5vij. M. 

Apply to the diseasad surface. 

It arrests hemorrhage, aborts discharge, and prolongs life. 

Gellhorn lauds the employment of acetone for producing such a hard- 
ening of the cancer tissues as to arrest the disagreeable odor and delay 
the progress of the disease. He first thoroughly curets the ulcerating 
surface. The crater of the cureted cavity is dried with cotton sponges 
and from one-half to an ounce of acetone is poured through a Ferguson's 
speculum, while the patient is in the Trendelenberg position, which she 
retains for from fifteen to thirty minutes. The fluid is allowed to run 
out and the cavity is packed with a narrow strip of gauze soaked with 
acetone. The healthy surfaces are cleansed and a cotton tampon in- 
serted to absorb the excess. Subsequent applications are made two or 
three times a week. For these applications it will be unnecessary to ad- 
minister an anesthetic. It is important to coat the vagina and vulva 
with vaselin to avoid contact of the fluid with the healthy surfaces. The 
effect of the remedy is to check oozing, alleviate the disagreeable odor, 
lessen and cause the discharge ultimately to disappear, and with it the 
offensive odor. 

Parenchymatous Injections. Various agents have been employed as 
injections into the structure of the cancer with a view to moderating its 
course or destroying it. Thiersch used nitrate of silver; Schramm, chlorid 
of sodium and sublimate. Mosetig-Moorhof and Stilling employed 
pyoktanin. Schultze has lately used injections of absolute alcohol in a 
large series of cases. Bernhardt employed a 6 per cent, solution of salicylic 
acid in 60 per cent, alcohol. Vulliet, independently of Schultze, has prac- 
tised the treatment with absolute alcohol. Under this treatment the bleed- 
ing and discharge were trifling or ceased entirely. After ten or fifteen in- 
jections the evil smell of the discharge disappeared and the pain ceased. 
Treatment, in the beginning, should occur at intervals of a few days. 
During the intervals the vagina may be tamponed with iodoform gauze. 
In the course of weeks or months the ulcer heals and the infiltrate dis- 
appears. Schultze suggests that when the injection is in the neighbor- 
hood of the peritoneum, the after-treatment is painful. Schramm found 
the injections painful and without special influence. The treatment has 
to be continued over weeks and months — a requirement that can be 
carried out only in rare cases. Without question, better results will be 
obtained by the use of the curet and the thermocautery. 

A. Martin, in incurable cases, advocates suturing the wound surface oc- 
casioned by the curetment. The carcinomatous masses are removed with 



PUERPERAL TUMORS. 735 

the sharp spoon and the parametrium is ligated; then, drawing down the 
uterine stump, strong curved needles are passed under the entire wound 
surface to the border of the neck or to the mucous membrane, and the 
thread is so secured that it brings together the wound surfaces created by 
the curetment. In an extensive wound the entire pelvic body is protected 
by a mattress suture, when the mobility of the stump is so limited that 
it is impossible to accomplish the partial sewing of the wound surface. 
The vagina is so sutured in the depth of the crater that a continuous 
series of firm sutures come to lie about the opening. However, the opera- 
tion frequently is impracticable, because extensive cavities with strong 
infiltrated walls are involved. The advantages offered by the method are 
that hemorrhage is controlled securely and that after-hemorrhages do not 
appear. The patient is spared the suppuration which follows the caustic, 
and a firm scar is formed. Houzel and Chrobak have seen good results 
from suturing. The method, however, is applicable only to a limited 
number of cases, and frequently offers great technical difficulties. Sutures 
often will cut through the carcinomatous tissue; sometimes the wound 
surfaces break apart, and suppuration again follows. The reported 
good results are less from the suture of the wound surface than from the 
union with the parametrium. 

A class of cases will be found in which the disease is so extensive that no 
palliative operation will afford relief, but the physician endeavors to make 
the patient comfortable and must relieve the distressing symptoms. 
These are hemorrhage and profuse offensive discharge. The latter be- 
comes so disgusting as to be distressing to the patient and to those about 
her. Local treatment is demanded. Syringing and tamponade with wet 
or dry dressings come under consideration. The control of hemorrhage 
is accomplished more effectually by the tamponade than by syringing with 
astringents. Kehrer employed the tampon with cotton gauze saturated 
in an 8 to lo per cent, solution of acetic alum. Iodoform gauze also 
exercises a good influence upon the smell of the discharge, but through 
long employment the odor of the idoform becomes persistent and annoying. 

The dry treatment, introduced by Sanger and employed by Fritsch, 
often proves beneficial, though it requires medicinal help in order to 
carry it out. It may be employed alternately with injections. The dry 
treatment follows curetment and cauterization. Iodoform is blown into 
the vagina, which is then firmly tamponed with iodoform gauze. Tam- 
ponades covered with iodoform may be introduced, and may remain as 
long as possible. This treatment should be repeated once or twice a 
week for some time. It controls hemorrhage, but especially keeps down 
the unpleasant smell of the discharge. The unpleasant odor of the 
iodoform and the existing danger of intoxication have led to the substitu- 
tion of tannin and boric acid and salicylic acid for similar purposes. 
Torggler employed charcoal powder with iodoform, which deodorized 
the mixture ; the ulcerated surfaces were rapidly cleaned. Long-continued 
sitz-baths often have a beneficial influence and afford the patient great 
relief. When penetration of the bladder occurs, the patient may keep 
herself comparatively comfortable by wearing a urinal. 



736 GYNECOLOGY. 

Fredric Gwyer has advised the use of powdered thymus gland in 
doses of 5i~iii three times daily. This powder, however, is so disagree- 
able in smell and taste as to make it so difficult to take that a watery 
extract can be made more palatable. It is claimed that the drug lessens 
pain, arrests growth, decreases hemorrhage and discharge, and improves 
the general nutrition. In the few cases in which I have used it, the drug 
seemed to justify the claims made for it. I have seen wonderful results 
from the use of the Rontgen ray treatment in superficial and metastatic 
deposits, but have never been able to see improvement where the disease 
was confined to the depths of the pelvis. 

It is important that the patient should be kept out of bed as long as her 
strength will permit. When once she becomes bedridden her condition 
is made worse, and the psychic depression is more marked. It requires 
the greatest cleanliness and most continuous care upon the part of the 
nurse to limit the occurrence of bed-sores, as the continuous and abundant 
discharge keeps the parts wet, and in emaciated persons with feeble 
powers of resistance the skin becomes broken and extensive bed-sores fol- 
low. In these enfeebled patients it is not to be expected that the loss of 
substance will be recovered, and scarcely that the wound surface can be 
kept clean. By the processes of absorption from the wound surface and the 
breaking down cancer, the patient soon has an elevation of temperature 
which aggravates the discharge. It is not worth while to give antipyretics 
to break down the temperature elevation in these cases as they have but 
a trifling influence and soon arrest nutritive processes. A local application 
of equal parts of salol and aristol has been employed with advantage. 
When the patient is unable to be under medical treatment continuously, 
resort must be had to irrigation. The entire series of antiseptic measures 
have been used; injections of permanganate of potash, one to two tea- 
spoonfuls of 5 per cent, solution in a gallon of water, is one of the best. 
The drug is cheap, and possesses the advantage that the patient is using a 
substance that. does not irritate nor burn, is completely odorless, and is an 
excellent disinfecting fluid. It has the advantage over the phenols that 
the peculiar smell of the latter, mixed with that of the cancer discharge, 
soon annoys the patient. Martin recommended for a deodorizing injec- 
tion a solution of 3 per cent, hydrogen peroxid with i per cent, thymol. 
Various astringent fluids, as pyroligneous acid and alum solution, are 
favored. 

If penetration of the bladder and rectum has resulted already, the 
patient is in a condition which makes it impossible to render her comfort- 
able. Tampons saturated with fatty or oily mixtures, such as bismuth 
salve, can be employed. The discharge sometimes is held back thus, but 
the continued irritation of the parts results in an excoriation eczema of the 
external genitalia, which is a new source of torment for the unfortunate 
patient. In such cases the removal of the disagreeable odor is no longer 
possible. In patients suffering from edematous external genitalia covered 
with excoriations and ulcers, and from already existing edema in the lower 
extremities, irrigation is very difficult, and is practicable only under increase 
of pain. Covering the lower extremities with a rubber skirt, by which the 



PUERPERAL TUMORS. 737 

odor is prevented from rising, has been advocated, but the moist warmth 
thus engendered soon renders it unbearable. Fritsch advocates com- 
pletely covering the vulva and the inner surface of the thighs with fre- 
quently changed pads wet with chlorin water, and thus destroy as much as 
possible the offensive odor. 

As these patients may continue to live in this uncomfortable condition 
for a long period, it would seem to me justifiable to avoid the fecal and 
urinary discharges by an artificial anus and draining of the pelves of the 
kidneys. To prevent the admixture of these discharges enables the patient 
to be less repellent. When the disease is far advanced, unless the meas- 
ures suggested have been employed, neither the greatest cleanliness nor 
the admission of fresh air to the sickroom is sufficient to drive out this 
horrible odor, and the patient becomes a source of discomfort to herself 
and to those who attend her. Anorexia makes itself noticeable early. 
This undoubtedly is due to the influence of the sickening odor upon the 
appetite. Every form of food becomes absolutely repugnant, and the 
patient is obliged to confine herself then to the smallest quantities of liquid 
nourishment. Sometimes these are taken more readily when cold. 
Patients frequently live for a remarkable length of time with scarcely any 
nourishment. The relief occasioned by the removal of the odor usually 
results in the improvement of the appetite. Obstinate constipation be- 
comes a marked symptom, which also acts unfavorably on the appetite. 
When evacuation occurs, it is so extraordinarily painful, because of the 
hard infiltration in the pelvis, that the patients are constrained to avoid 
defecation in order to escape the pain. Large enemas are better than 
purgatives in such cases. An enema of one-half to one pint of kerosene 
will frequently have a salutary effect in emptying the bowel. Of course, 
if a rectal fistula exists, the enema will not be practicable. The uncontrol- 
lable vomiting which marks the advent of a uremic condition is an exceed- 
ingly distressing symptom. Occasionally, the administration of diuretics 
will relieve it. The condition of the urinary secretion should be observed. 
Any failure should be an indication to administer diuretics, by which the 
appearance of vomiting can be prevented. 

In the later stages the third distressing symptom is pain, which can be 
avoided only by the free use of narcotics. The only hesitation in the ad- 
ministration of narcotics should be to avoid their too lavish use early. 
The patient who becomes accustomed to large doses of the narcotics, 
may reach a stage at which they are needed still more seriously. She then 
will have become so inured to the drug that she can no longer find relief. 
Early in the disease it is better to employ remedies which will give a slight 
anodyne effect in place of the narcotics. Antipyrin has been found 
effective. In extensive infiltration involving the lateral and posterior parts 
of the pelvis this remedy is useless. Such cases are relieved by rectal 
suppositories containing : 

I^. Morphin sulph., gr. i 

Pulv. opii pur., gr. i 

Pulv. belladon., gr. ^ 

Ol. theobrom., ad gr. xx. 

Ft. supposit. 

47 



738 GYNECOLOGY. 

Such a suppository, given at night, relieves the distress, secures sleep, and 
delays the need for larger doses of morphin. An additional advantage is 
that by such a combination we can increase the dose and give the patient 
the prescribed daily ration which she will require. Codein may be given 
in pill form. In the later stages of the disease only the subcutaneous use 
of morphin in increasing doses will afford relief. Fortunately for the 
patient and her relatives, toward the end of the disease the compression 
and obstruction of the ureters occasionally cause sufficient uremia to 
obtund the general sensibility and lessen the discomfort. The soporose 
and comatose conditions are frequent, and increase the comfort of the 
patient. Cumston's proposition to relieve the obstruction by establishing 
a ureteral fistula or performing a nephrotomy should receive no considera- 
tion, as the inevitable fatal conclusion is better early than later, and to 
prolong life is but to prolong suffering. In advanced stages Drszewczky 
claims benefit from an ointment of extract of condurango and vaseHn. 

328. Pregnancy Complicating Carcinoma. We have already 
spoken of the occurrence of pregnancy as a complication of carcinoma — a 
complication which is fraught with the greatest danger to two lives. It 
was stated that the treatment would entirely depend upon the progress of 
the disease. Thus, if the disease was incurable, and there was no possible 
chance for the mother, every effort should be made to prolong the preg- 
nancy to full term or to viability of the child, in order that it should have 
a chance for its life; when, however, the disease is operable and there is 
hope for a radical cure of the patient, no consideration for the child should 
operate against the mother's chances. The continuation of the preg- 
nancy is doubtful, and attended with improbability of the child being 
delivered alive. Danger to the mother is greatly increased, with almost 
the certainty that the progress of the disease will be so rapid that at the 
termination of pregnancy the time for radical treatment will be found 
to be past. Under such circumstances the proper consideration is the 
life of the mother. If the pregnancy has not reached the fourth month, 
we may proceed to the removal of the uterus per vaginam. Emptying the 
uterus reduces its size and renders easier its subsequent removal through 
the vagina. During and after the fourth month the operation should be 
performed through the abdomen. Between the fifth and seventh months 
we may be governed by the condition as to whether we wait for viability 
or proceed to immediate operation. If the disease is apparently progress- 
ing rapidly, an operation should be done immediately, without regard to 
-the child. We may resort to an abortion, and then operate through the 
vagina, or the abdomen may be opened. In advanced pregnancy Martin 
has advocated the supravaginal amputation of the uterus and the extirpa- 
tion of the carcinomatous cervix by the vagina. The advantages of this 
procedure are that the abdomen is kept open but a short time, that the 
hemorrhage can be controlled better from below, and that the carcinoma- 
tous masses are not drawn back through the abdominal cavity. Of six 
patients thus operated upon, one died of septic peritonitis. In the last two 
months of pregnancy we have to consider the treatment which has in view 
the preservation of two lives. Cesarean section should be performed, 



PUERPERAL TUMORS. 730 

which is followed by a Freund abdominal, the Zweifel combined, or, 
finally, the pure vaginal total extirpation. Of these procedures, the ab- 
dominal operation seems preferable. 

We come next to the consideration of operable carcinoma in labor. 
Here we have the possibility of a spontaneous ending of labor through the 
diseased passages. This may be considered, if the disease is still in the 
early stages. If the carcinomatous infiltration has not involved the entire 
portio, and a more or less large zone of the uterine margin remains free 
and capable of dilating, the ovum may be extruded thus. When the 
carcinomatous masses cannot be crushed by the head, they should be 
cut away with scissors or the thermocautery as a preliminary, and the 
child should be delivered by forceps or by version. If the ovum is dead, 
its size may be diminished by perforation or by piecemeal operation, 
whichever will end the labor most effectively and in the best manner for 
the mother. Following the delivery we may consider immediate vaginal 
total extirpation, or its delay until the second week of the puerperium. 
The delay in these cases is suggested because of the size of the uterus. 
The advantages of the procedure, however, are that the uterus permits- 
itself to be brought readily to the vulva, and that the wall of the vulva and 
the vagina have been so distended by the passage of the fetus that they do 
not afford an artificial hindrance. Occasionally, the size of the uterus 
affords difficulty. It can then be reduced by splitting it into two parts in 
the median line, but this endangers the reimplantation in the wound, 

329. Summary. In the discussion of the subject of cancer I have 
endeavored to give a comprehensive view of the methods by which the 
disease can be combated. As such a statement must be, however, more 
or less confusing to the student, it is my purpose in this section to present 
briefly the indications for special treatment. The two principal methods 
of treating curable cancer are by the abdominal and vaginal routes. 
The sacral method affords no advantages which render it worthy of con- 
sideration. When the uterus is large and the disease has evidently ex- 
tended to, if not into, the parametrium and is complicated with myoma, 
ovarian tumor, or the later stages of pregnancy, or when the vagina is 
undilated and narrow, abdominal hysterectomy should be preferred. 
Vaginal hysterectomy when carcinoma is limited to a uterus freely 
movable, not too large and accessible through a roomy vagina, has been 
the operation of election. The after-results, however, have demonstrated 
that vaginal hysterectomy, as ordinarily performed, is ineffective in that it 
does not afford opportunity for the removal of sufficient tissue to insure 
against early recurrence. The operator should keep two objects in mind 
in proceeding to perform any operation for carcinoma: i. To insure the 
removal of a diseased organ in a healthy field, which is accomplished where 
possible by the removal of the upper part of the vagina and as much 
parametrial tissue as safety for the ureters and bladder will permit, thus 
getting beyond the isolated nests, which may be situated in the para- 
metrium; 2, the exercise of such precautions as will avoid the implantation 
of cancerous material upon the healthy wound. 

In the vaginal operation the operator has the choice of three methods 



740 GYNECOLOGY. 

of procedure for the control of hemorrhage. These are the use of pressure 
forceps or clamps, the electric cautery, and the ligature. The clamp 
procedure has the advantage of being more expeditious, in favorable cases 
permitting the removal of the uterus in a very few minutes. It has the dis- 
advantage that it produces an increased amount of pain, from the weight 
and dragging of the clamps and the necessity of the patient being confined 
to the dorsal position. The retention of the clamps produces a certain 
amount of necrotic tissue in the peritoneal cavity after removal of the clamp, 
and causes increased danger of septic infection. The removal of the 
clamps, often as late as forty-eight hours, is sometimes attended with 
quite free after-bleeding, which may require their reapplication, under 
very great disadvantage, in order to prevent the death of the patient from 
hemorrhage. In a large hospital where there is a convenient electric-light 
plant or connection with the street current can be made, the electrocautery 
is ideal, otherwise it means the employment of special apparatus, which is 
cumbersome and requires expert skill to manage and maintain in order. 
The ligature method is slower than the clamp, but the hemostasis is more 
sure and the comfort of the patient increased during convalescence. Cat- 
gut is preferable to silk for ligation, because the latter is likely to become 
infected, cause sinus granulations and discharge will continue until the 
ligature disintegrates, sloughs away, or is removed, and causes worry 
and distress to the patient, inducing her to believe that the disease has 
recurred. 

In performing an abdominal hysterectomy the method suggested in 
§ 326 is the proper course. The uterine arteries should be ligated sepa- 
rately near their origin, the course of the ureters observed, and an extensive 
removal of the parametrium and upper part of the vagina made. This 
procedure, in my judgment, is more important than the removal of glands. 
Before closing the wound, bleeding vessels are carefully secured. When 
there is much oozing or a large surface has been denuded of peritoneum, 
gauze is carried through the opening into the vagina, packed into the cel- 
lular tissue upon each side, and the peritoneum united over it by a con- 
tinuous catgut suture. The abdominal cavity is cleansed; the wound is 
closed as in ordinary abdominal procedures. The gauze packing in these 
cases may be left in for from six to eight days and then be removed through 
the vagina. 

330. Chorio-epithelioma Malignum. Some twenty years ago a 
condition intimately associated with pregnancy was recognized as a form 
of malignant disease. (Fig. 543 .) It has been described under the various 
names of deciduoma malignum, deciduomatous sarcoma, sarcoma deciduo- 
cellulare, blastoma, deciduo-chorion cellulare, syncytium carcinoma, 
syncytio malignum, the destructive bladder mole, destructive placental 
polyp, and the title of our section, chorio-epithelioma malignum. These 
various designations indicate the attempts upon the part of the different 
investigators to name the structural origin of the condition. (Fig. 544.) 
It was formerly supposed to be due to the degenerative changes resulting 
from a cyst mole, from which metastases were carried by the veins to 
different points, and growths of the similar epithelial structure followed. 



PUERPERAL TUMORS. 



741 



Later investigations, however, have disclosed that a mole is not necessary 
to its development, although favoring its growth. 

Recent investigators agree that the disease arises from the fetal cells, 
composing the viUi and chorion, the Langhan's and the syncytial cells. 
The gravity of the condition seems to depend on which class of these 
cells predominates. When the disease originates in the Langhan's layer, 
it is extremely malignant: when from the syncytial cells, comparatively 
harmless. 

Marchand, in 1895, asserted that there were two types, the typical 
and the atypical. His typical form exhibited extreme variations in its 
structure and course. Schlagenhaufer, in 1899, taught that recovery 
might follow: i, Spontaneous expulsion of the tumor from the uterus; 2, 




m,Mkt 



Fig. 543. — Chorio-epithelioma of the Uterus. 
a, a, a, a. Nodules of neoplasm, h. Stump of round ligament, c. Thrombus projecting 

from ovarian arterv. 



the use of the curet; 3, partial removal of the tumor by the knife, the re- 
mainder being left in the pelvis. Schwank, on the other hand, had such 
unfavorable results that he considered it a crime to operate. This diver- 
sity of opinion led to more careful investigation and Dr. James Ewing, 
of New York, gives the following classification: i, Syncytoma, a typical 
choriona of Marchand, in which there is more or less diffuse infiltration of 
the myometrium, forming a large tumor which enlarges the uterus without 
perforating it and does not produce metastases. The structure of the 
growth consisted of large wandering syncytial cells, found in the walls of 
sinuses and the musculature. 2, Chorio-adenoma destruens, malignant 
placental polypi. The sinuses of the uterus were infiltrated, causing en- 
largement, without splitting, of a compact growth. Metastases occurred in 
lungs and vagina. Its structure showed villi, Langhan's cells and syn- 
cytium in more or less orderly arrangement. 3, Choriocarcinoma, a 



742 



GYNECOLOGY. 




Fig. 544. — Chorio-epithelioma Malignum. (Section furnished by Drs. C. P. Noble and 

S. E. Tracy.) 
a, a. Large syncytial cells, h, Blood detritus. 




Fig. 545. — Histologic Section of Chorio-epithelioma. 

a. Collection of large decidual cells. 0, b, b, b. Chorionic vilU showing proliferation of their 

cellular coverings, c. Large multinucleated cell containing a vacuole. 



PUERPERAL TUMORS. 743 

relatively small circumscribed tumor in the musculature which tended to 
perforation of the uterus without its enlargement, and resulted in both 
local and general metastases. The structure consisted of Langhan's 
cells and syncytium in masses often imperfectly differentiated. 

Etiology. The disease occurs during the period of active reproductive 
life and follows an abortion, either intra-uterine or tubal, a normal labor, 
or frequently a hydatid mole. The disease is not dependent upon preg- 
nancy necessarily, for it has been recognized in the unmarried woman and 
in the testicle of the male. In such cases it is supposed to originate in 
inclusion cells. The occurrence of the disease has been attributed to 
want of nourishment in the villi. Pick and E. P. Davis report cases in 
which the disease has developed during pregnancy and Pick reported a 
tumor situated in the posterior wall of the vagina, which, upon removal, 
contained distended chorionic villi with proliferated syncytial cells. 

Symptoms. In a few days to a few months following the termination 
of a pregnancy the patient suffers from repeated bleeding. As this in- 
creases in severity, the patient becomes markedly anemic. There will also 
be a profuse dirty, watery discharge. The continued drain, the hemor- 
rhage and discharge, give rise to extreme weakness and a cachectic appear- 
ance. Curetment of the uterus in a condition like this results in the re- 
moval of a varying quantity of soft, friable material, which looks like 
placenta and bleeds freely. Oftentimes it will contain necrotic tissue, 
causing an extremely offensive odor. Very frequently, on the anterior 
wall of the vagina, a metastasis in the form of small round masses will 
be observed. On being opened, this will present tissue similar to that re- 
moved from the uterus. Similar metastases result in the formation of 
growths in other portions of the body. Thus it has been carried to the lungs, 
pleura, diaphragm, spleen, pericardium, kidney, liver, intestines, or even 
the brain. When the diseased tissue is cureted from the uterus, the patient 
has but temporary relief; hemorrhages again return, and a second curet- 
ment will remove tissue similar to that which was found at first. 

Diagnosis is easy in advanced cases, but difl&cult in early stages. It is 
determined both by clinical observation and microscopic investigation. 
The rapid return of hemorrhage after curetment, in which no fetal pro- 
ducts are found, the foul discharges, the profound anemia, elevation of 
temperature, large uterus, dilated os, soft friable tumor, and the metastasis 
with the revelations of the microscope, should render the diagnosis positive. 
The rapid cachexia should awaken suspicion. The disease so closely 
resembles both carcinoma and sarcoma as to render it difficult to 
differentiate between them. The structure having no stroma and being 
disseminated by the blood-vessels rather than by the lymphatics, makes it 
closely akin to sarcoma. From sarcoma, however, it is differentiated by 
the fact that it is composed largely of epithelial elements. 

Prognosis depends upon the particular manifestation. An early 
recognition is of the greatest importance and equally so is the determina- 
tion of the particular form. In the first form an early curetment and in 
the second a curetment or partial removal may prove curative. In the 
third the only hope is in the prompt extirpation of the uterus. Marchand 



744 GYNECOLOGY. 

reports twenty-eight cases with twenty-four deaths. It is one of the 
most malignant of growths and the third form frequently terminates in six 
months, whether operation is done or not. Veit reported recovery after 
metastases had occurred, but this was evidently in the second form 
(page 741). 

The frequent difficulty in diagnosis is well illustrated by the history of 
the following patient, kindly given me by Dr. M. F. Herman, of this city. 
"Mrs. M. L., a woman of thirty-three years, came under my observa- 
tion in August, 1908, stating that puberty was established at the age of 
thirteen years, periods regular, lasting three to four days, scanty, and at- 
tended with pain the first day. She married at the age of twenty-eight, 
and two years later gave birth to a child after a normal labor, thirteen 
months subsequent to which she became pregnant again; then the labor, 
five weeks early, was complicated by adherent placenta, a part of which 
was retained and thrown off three days later. The first child was a girl, 
the latter a boy, and it died eighteen months subsequently with tubercular 
meningitis. Five months after the death of the child, she again became 
pregnant, but aborted at the fourth month without special reason and 
was confined to bed for two weeks. Another pregnancy occurred at the 
end of nine months, the patient having menstruated but twice following 
the abortion. She aborted in this pregnancy, again at the end of four 
months, and was cureted, when a large amount of friable tissue was re- 
moved, of which no microscopical investigation was made. The patient 
got about in two weeks, but continued to suffer profuse, irregular bleeding, 
and two months later was again subjected to curetment, when an equal 
quantity of friable tissue was removed. Hemorrhage was arrested for a 
short time, but again became profuse and was so excessive that she was 
taken to St. Joseph's Hospital, where she was cureted by one of the staff 
of that institution, and the same kind of tissue removed as in the two 
former curetments. A blood examination then showed : 

Leukocytes 7j5oo 

Erythrocytes 3,000,000 

Hemoglobin 50 per cent. 

She left the hospital in two weeks, but the former symptoms prompdy 
returned in aggravated form, when Dr. E. E. Montgomery was called and 
diagnosed the condition as chorio-epithelioma. She was again removed 
to the hospital, where he did hysterectomy. The blood-count at this 
time gave : 

Leukocytes 8,500 

Erythrocytes 2,500,000 

Hemoglobin 40 per cent. 

The operation was followed by an uninterrupted convalescence, and the 
patient has since enjoyed good health. Her weight has increased from 
102 to 147 pounds, and she regards herself in perfect health now, over two 
years subsequent to the operation." 

For the following pathological report I am indebted to Dr. P. Brooke 




Fig. 546.— Uterus Containing Mass of ChoHo-epithelioma in Case of Dr 



Herman. 



PUERPERAL TUMORS. 



745 



Bland. "The specimen received for examination consisted of the uterus, 
tubes, and ovaries. The appendages show no gross pathologic change, 
but the uterus is uniformly enlarged and about three times its normal size. 
In consistence it is soft and elastic, and a considerable sized mass can be 
palpated through the uterine wall and is also recognized by introducing 
the finger through the uterine canal, when it offers the sensation of a sub- 
mucous fibromyoma. The wall of the uterus was easily incised and much 
thickened from enlargement and edema. Opening the cavity disclosed an 
ovoidal tumor the size of a tangerine orange, of a bluish-purple color, 
resembling an organized blood-clot, which was attached by a broad base 
to the posterior uterine wall. The tumor was moderately firm in consist- 
ence, and when cut open through its attachment to the uterine wall was 




Fig. 547. — Microscopic Section of Chorio-epithelioma taken from Fig. 546. 



found to have infiltrated the latter through more than one-half of its 
normal thickness. (Fig. 546.) Uterus contains growth diagnosed as 
chorio-epithelioma. Microscopic examination of stained sections dis- 
closed different elements; mostly the tissue is composed of syncytium, 
large decidual cells, blood detritus, and blood sluice-ways. The syn- 
cytium appears as large masses of protoplasm of various shapes, rounded 
drawn-out bands and whorls, or irregular masses. These areas are vacuo- 
lated and in many portions contain considerable blood. These proto- 
plastic masses are occasionally broken by spaces which are possibly blood- 
channels, as many of them are filled with blood-cells. In portions of the 
sections, collections of very large oval and round cells are seen. These 
cells are generally congregated in masses, and as a rule are found on the 
border-line of the blood-channels. They are unusually large and con- 
tain large oval and prominent staining nuclei. Their protoplasm is 



746 



GYNECOLOGY. 



pale and generally ill-defined. These cells have the general characteristics 
and appearance of the decidual cells and exhibit marked nuclear activity. 
In some areas of the sections, leukocytic infiltration is observed, though 
not so marked. None of the sections betrayed the presence of chorionic 
villi. Those taken from the line of invasion disclosed cell-infiltration of 
the mural substance of the uterus. 

Histologic diagnosis: Chorio-epithelioma malignum. 

In the extirpation of the disease the abdominal operation is preferable, 
for the reason that there is less danger of fragments of the tissue being 
forced into the veins. 

331. Endothelioma Uteri. A comparatively recently recognized 
form of malignant disease occurs in various tissues of the body and is 




a, a. Endothelial 



Fig. 548. — Endothelioma of the Uterus. 

cells infiltrating lymph-spaces, h. Blood-cells. 

matrix. 



Connective-tissue 



known as endothelioma. It has its origin in the endothelial lining of the 
blood- and lymph-vessels and the serous membranes. Endothelioma 
manifests itself in many ways, according to the structures involved 
and [the particular endothelium from which it has originated. The 
disease may occur in the cervix, although this is extremely rare, and 
resembles closely the squamous-cell carcinoma. Diagnosis can only 
be determined by the employment of the microscope. Examination of 
the section of tissue reveals the squamous cell-layer intact, free from 
any infolding process or tendency to project into the underlying tissue. 
The growth consists of spaces lined by one or more layers of cells, 
resembling lymph-spaces. Where these spaces are obliterated by masses 
of proliferative cells, there is a resemblance to the squamous nests, but 
in the latter the outer layer assumes a cuboidal or more cylindrical 



PUERPERAL TUMORS. 747 

form and the nuclei are more vesicular. (Fig. 548.) When the disease 
involves the body of the uterus, it is likely to form a tumor of consid- 
erable size, and in its course and progress will resemble sarcoma. 
Metastases usually occur through the blood-vessels. In my own expe- 
rience, I have noted that it is prone to extend upon the peritoneal surface 
and result in the formation of numerous nodules over the peritoneum, 
and frequently eventuating in intestinal obstruction. Unless the latter 
symptoms occur, the disease is singularly free from pain the patient 
complaining rather of the progressive emaciation and the continuous loss 
of strength. The prognosis is unfavorable, since the disease progresses 
by both the lymph- and blood-vessels, but more frequently by the latter. 

332. Sarcoma uteri can involve either the mucous membrane or the 
wall of the organ, and hence is divided into two groups. Clinically it is 
found either in the body or in the cervix — more frequently in the former — 
and this holds true in both its anatomic varieties. Sarcoma of the mucous 
membrane is one and one-half times more frequent than the same infection 
of the wall. It differs from carcinoma in that it is a growth which springs 
from the connective-tissue cells, the latter from the epithelial. 

Varieties. Sarcoma is divided into sarcoma of the cervix and sarcoma 
of the body. Sarcoma of the cervix occurs generally as grape-like clusters, 
protruding from the cervical mucous membrane, and it is also called 
sarcoma colli uteri hydropicum papillae, or, from its grape-like appearance, 
sarcoma botryoides. From its soft appearance it has been described as 
myxomatous, but Pfannenstiel says this condition is due to a form of 
lymphedema. In the body of the uterus the disease may occupy the 
mucous membrane or the mural structure of the organ, and be either 
diffuse or circumscribed. Sarcoma of the uterine wall arises in either the 
mural portion of the uterus or from degeneration of a fibromyoma. 
The latter origin is regarded as the more frequent. It is often difficult to 
make certain whether the disease has originated as a primary sarcoma of 
the wall or from a myoma. When it is recognized as situated in a myoma 
or surrounded by myomatous tissue, the latter is evidently its source. 
Where the myoma is associated with a sarcoma which involves the ad- 
joining tissue as well, the origin may remain doubtful. Sarcoma of the 
mucous membrane overlying a fibroma is frequently observed. 

Pathology. Sarcoma involving the mucous membrane occurs in the 
diffuse and polypoid forms. The former does not necessarily involve the 
entire surface, like a fungous endometritis, but appears as a more or less 
circumscribed growth, from the surface of which there are irregular pro- 
jections, giving the new formation a roughened, often villous appearance. 
The polypoid variety is nearly three times as frequent, both in the body and 
in the cervix. Sarcoma of the mucous membrane is twice as frequent in 
the body as in the cervix. The grape-like clusters, already mentioned, 
protrude from the external so suspended by a pedicle. The extremities 
of these projections are soft, oftentimes easily broken down, and they form 
a dense cluster protruding from the os, in which the different portions of 
the growth are molded or flattened by pressure. The polypi arise by a 
firm, more or less broad pedicle from the mucous membrane of the cervical 



748 



GYNECOLOGY. 



canal and project from the external os into the vagina, showing a great 
resemblance to a mole. While the foundation part of the new formation 
of the cervical canal consists of firm, fibrous tissue, the vaginal portion is 
strongly edematous, soft, almost fluctuating, and easily broken down. 
The growth has a pedicle which often is thinned and drawn out, made up of 
a number of individual berries which are situated so close together that 
they are flattened. (Fig. 549.) They vary in size from a grain of corn to 
that of a grape, and their stalk shows a smooth, moist, glistening surface 
of a yellowish-white, brownish, or blue-black color, alterations which are 
produced by the entrance of blood into the tissues. The berries are most 
often bluish in color, and in some places vitreous changes are seen. The 




Fig. 549. — Sarcoma of the Body of the Uterus. 
a, a. Characteristic appearance of blood-vessels minus distinct wall, the wall being formed by 



the malignant cells. 



berry contains a bright or light yellow fluid and collapses upon its escape. 
These projections, however, usually have about the appearance, if not the 
consistency, of a mucous polypus. The growth has its origin in the su- 
perior layer of the mucous membrane and assumes the grape-like form 
only after its extrusion into the vagina. This form is produced by inter- 
ference with the circulation from pressure upon the pedicle, which, as a 
rule, causes edema and swelling of the intravaginal portion. The disease 
progresses slowly, but often is carried and disseminated by the blood- 
vessels. The individual cells are mostly of the roundish or spindle form. 
Between them almost uniformly is found a very fine intercellular substance. 
Parts of the new formation are divided by fissures or ramifying spaces, 
which, from the high cylindric epithelium and the nuclei situated in the 
cells, are recognized as the cervical glands. These glands are not sufii- 



PUERPERAL TUMORS. 749 

ciently numerous to justify the appellation of adenosarcoma, a term some- 
times applied to them. The diffuse form affects the body. Its progress is 
slow and it extends upon the surface, showing great reluctance to the in- 
vasion of the subjacent wall. As it follows the surface it is manifested by 
large or small nodular papillary or villous projections. The mucous sur- 
face begins to degenerate and hemorrhage appears. In rare cases the 
muscular structure is rapidly involved. Generally the tissue involved 
exhibits a reduction in its vascularity. When the vessels are specially 
abundant, it is designated as the hemorrhagic or telangiectatic variety. 

The appearance of a section of sarcoma is quite varied. The less 
connective tissue present, the more homogeneous it appears. Most 
generally it is marrow-like, and, in advanced stages, presents a soft, 
smeary, and very fragile mass. With an increase of the connective tissue 
the borders are folded and irregular, inclosing a homogeneous section. 
The structure undergoes marked changes under myxomatous alteration 
or serous penetration, and not infrequently apoplectic nests are recognized 
and cysts are formed. 

The muscular walls are especially resistant, and become thickened, 
while the disease extends in the direction of the least resistance, which is 
into the cavity of the uterus. Usually the uterus is not enlarged; when it 
becomes so, the enlargement is uniform. The uterus is hard or soft, 
according to the degree of extension. In rare cases the progress of the 
disease and uterine hypertrophy are simultaneous. Under these cir- 
cumstances the growth attains to the size of a child's head; in rare cases it 
shifts to the internal os and causes severe hemorrhage, serous discharge, 
or purulent destruction. In rapid extension the tumor can reach the ribs. 
Occasionally it penetrates the uterine wall, projects upon the peritoneal 
surface, involves the peritoneum or the intestine, results in suppurative 
peritonitis, and death rapidly follows. It can become encapsulated and 
penetrate the intestine or the abdominal wall, and form a fistula. Fistulas 
of the rectum and bladder are rare in sarcoma, but frequent in carcinoma. 
The disease seems inclined to limit itself to the uterus, and metastasis to 
other organs occurs late. The disease can grow through the uterus and 
involve the parametric tissue, but this only in advanced cases. A polypoid 
growth may extend and fill up the uterine cavity and lie upon healthy 
tissue without involving it. 

Sarcoma of the wall appears in a rounded form, with folded or lapped 
borders. The uterus is hypertrophied. Section of such a tumor shows 
a yellowish-white or grayish-red surface. The discharge is a milky, soft 
tissue, and its structure would indicate that it had originated in a fibro- 
myoma. It is very difficult to decide whether the myoma is a cause or a 
coincidence. A myoma is not infrequently situated near a sarcoma of the 
mucous membrane, from which it can become involved. Polypoid growths 
are occasionally the size of a fist, and may have a broad base or along, thin 
pedicle. ^Vhen a polypoid growth pushes into the cavity, the remaining 
portion of the mucous surface may remain long uninvolved. The exist- 
ence of the new formation develops an inclination to expel it as a foreign 
body, by which the os is dilated, and the tumor, hanging by a pedicle, is 



75© GYNECOLOGY. 

extruded into the vagina. Portions of the tumor may disintegrate and 
be discharged. The cervical form of the species is rare, but sometimes 
projects from the os as a grape-like cluster, which may fill out the vagina 
and may even project from the vulva. These polypi most frequently 
originate from the posterior cervical wall and are soft growths, which 
show but little inclination to break down. 

A second form resembles the cancroid, but is softer, less easily broken 
down, and does not so rapidly seize upon the other lip. The spindle-cell 
structure predominates in the cervical tumors. Myxosarcoma and angio- 
sarcoma are frequent. Sarcoma of the cervix shows but little disposition 
to invade the uterine body or the vaginal vault. It most frequently pene- 
trates the cellular tissue of the parametrium. 

Growths are described as spindle-celled or round-celled, according to 
the variety of these cells which predominate, as none are pure. The 
diseased structure is surrounded by a zone of irritation cells, which are 
difficult to distinguish from the small round-cell. Weil reported the 
growths occurring in the relative frequency of 35 per cent, spindle-cell, 
45 per cent, round-cell, and 25 per cent, mixed-cell tumors. 

Ruge recognizes four Groups: i. Giant-cell sarcoma. The cells of the 
intervening gland tissue are largely increased. The cells — of round, 
sometimes spindle, form — are irregularly arranged, and their nuclei often 
exceed in size the usual cells. 2. The intermediate tissue cells, which are 
changed in the large spindle form to resemble the decidua cells. They 
are differentiated by their size, situation, and irregular form. 3. Small 
round or spindle cells, between which lie irritation cells. 4. Smaller 
round-cell sarcoma, which shows a great increase of cells, irregular in size 
and form. 

The influence upon the glands of the mucous membrane gives variety. 
Generally, the glands are compressed and disappear, but occasionally 
they are retained, and form extensive areas within the tumor, producing 
what is known as adenosarcoma. The origin of sarcoma is difiicult to 
fix; the microscopic appearance would indicate that it was from the 
coats of the vessels. A tumor in which there is a great increase of the 
vessels is known as an angiosarcoma. 

Disturbances in nutrition cause edema and swelling of the cells; this 
condition simulates myxomatous degeneration, and has been called 
myxosarcoma. Lymphosarcoma is the name applied to those cases in 
which the disease originates in, and follows the course of, the lymphatic 
vessels. Myosarcoma is an engrafting of the disease upon a fibroid, and 
the term adenosarcoma indicates that glandular tissue has been included 
within the growth. Fibrosarcoma usually exhibits a roundish growth. 
The entire new formation may present a degeneration into sarcomatous 
tissue, so that upon section it exhibits a soft, marrow-like structure, or 
may be somewhat firm and uniformly opaque, with moist or mottled sur- 
face. Frequently the tissue resembles fish flesh. At other times the 
myoma has undergone sarcomatous change only in parts of its structure, 
and these points of degeneration give the section a striated appearance, in 
which the nodules are distinctly recognized. The sarcomatous degenera- 



PUERPERAL TUMORS. 



/5 



tion is most frequently found in the center of the mass, so that it is sur- 
rounded by a myomatous crust. Gusserow's assertion that the fibro- 
sarcoma continually loses its capsule is of no significance, for not every 
myoma has a capsule. 

Fibrosarcoma may attain an enormous size, forming a tumor which 
reaches beneath the ribs. If the tumor is projected into the uterine cavity, 
it is generally covered by the mucous membrane which is not penetrated 
by the disease, and occasionally the tumor, thus covered, is extruded into 
the vagina. The submucous tumor mostly springs by a broad base from 
the wall of the uterus, in which no sarcomatous tissue is found. If the 
submucous tumor has attained a large size, disturbances of nutrition may 
have already occurred which lead to suppuration. The longer the growth 
exists, the greater the inclination to destruction, especially if it is soft and 
has grown rapidly. In the submucous growth the uterus tends to enlarge, 
especially when the tumor is of the interstitial variety. On the other hand, 
the intraligamentary subserous sarcoma produces an enlargement or alter- 
ation of the uterus, which should not be overlooked. 

These sarcomata, like the myomata from which they mostly project, 
are but slightly supplied with vessels, though they frequently have a 
distinct telangiectatic form. 

Much diversity of opinion exists as to what constituent of the wall 
affords origin for the sarcoma cell. Virchow attributed it to the inter- 
cellular substance: "Their cells increase by division, they consist more 
and more of round cells, beginning small, later larger, with considerable 
nuclei, as large mucous bodies, while the intercellular substance is looser 
and more spongy." Kahlden believed that sarcomatous degeneration 
resulted from the immediate transformation of muscle-cells into roundish 
cells; their poles then became oval or blunted. Whitridge Williams 
says that under rapid increase of the number of cells this section of tissue 
passes into pronounced spindle-celled sarcoma with irritation cells. 
Ricker explains the growth "naturally by a growing through of myoma 
bundles by the side of the sarcoma tissue." Ruge says, "The impres- 
sion exists, as if the fine, small muscle-cells passed over directly into the 
sarcoma cells." Gessner, from extensive investigations, concludes: 
" The round-cell sarcoma continually takes its origin from the connective 
tissue, and, likewise, the majority of the spindle-cell sarcomata; but that 
in all probability to the smallest part they lead back to an immediate 
transformation of muscle-cells." 

Etiology. The cause of sarcoma is unknown. Cohnheim's theory 
that it originates from some congenital defect affords no further information. 
In other parts of the body sarcoma is attributed to injury, but the occur- 
rence of rapidly developing sarcoma following trauma is no indication 
that the latter is the cause. Injuries during parturition, difl&cult delivery 
of the placenta, frequent labors, and blows upon the sacrum have been 
assigned as causes for its development. Labor, however, does not seem 
to be a factor, as two-thirds of the cases are below the average in child- 
bearing, and in a great majority there is a long interval between the last 
labor and the development of the disease. The cervix is most subject 



752 GYNECOLOGY. 

to injury during labor, while the body of the organ is more subject to the 
disease. Sarcoma, like cancer, is due to some chemical or toxic action on 
irritated cells and owe their difference to the structures involved. 

Predisposing factors are: Age. The cases of sarcoma of the mucous 
membrane preponderate between the ages of fifty and sixty, although a 
large number are found between the ages of five and twenty; sarcoma 
of the wall is absent in the young, while the maximum number is found 
between the ages of forty and fifty. Trauma, parasitic irritation, syph- 
ilis, and the presence of fibroids are included, but, if factors, the query 
becomes important, why are the cases not more frequent? Gusserow 
believed that the disease originated from changes in the fibroid, and 
Martin saw it follow the ergot treatment of fibroid in six cases. The 
latter number, however, is too small for a definite conclusion. Heredity 
as a factor is undetermined. Poverty has been given as a cause, but 
Weil has shown that one-fourth of the cases of sarcoma of the mucous 
membrane have occurred in the well-to-do. 

Symptoms. Sarcoma, like carcinoma, presents no characteristic 
symptoms. The more important indications or signs which should 
awaken suspicion of its existence are hemorrhage, discharge, pain, and, 
in advanced stages, cachexia. In more than one-half of the cases bleed- 
ing is the first symptom, and is rarely absent. It begins by increased 
menstrual flow, then a bloody, watery discharge, which is not sudden, 
as in fibroma, but more or less continuous. It comes from the associated 
endometritis, while a stronger flow is indicative of destruction of the new 
formation. Rupture of vessels and more or less severe hemorrhage 
occur in the diffuse variety, but the polypoid form does not break down 
readily. In the cervical variety the disease occurs quite early in life. It 
has been observed at two and one-half years and displays a preference for 
the young at the period of awakening to sexual activity. The earlier 
symptoms are similar to those of mucous polypus, such as hemorrhage 
and discharge. During sexual activity there is first increased menstrua- 
tion, then irregular discharge of blood, later pain, which results from 
the pressure of the increasing growth upon the cervix. The extension 
of the disease to the parametrium causes pressure upon the pelvic nerves 
and the formation of masses which press up the uterus and lift it out of 
the pelvis. The hemorrhage and diffuse discharge result in a high degree 
of anemia, and finally cachexia appears, and the patient ultimately perishes 
from marasmus and the penetration of the disintegrating tumor into the 
abdominal cavity with fatal peritonitis. In the frequently recurring 
sarcoma of the mucous membrane, which appears at the climacteric, 
hemorrhage is the first, and often for a long time the only, indication of the 
disease. The obstruction to the uterine discharge will frequently result 
in the formation of a pyometra or hematometra and the development of 
a tumor, which will reach to the ribs. The uterine collection may be 
bloody or mixed with tissue and it often attains an enormous size. Dis- 
charge is the first symptom in about one-fourth of the patients and 
does not cease with the further progress of the disease. It begins as a 
quite abundant, thin, watery fluid, which is later mixed with blood. 



PUERPERAL TUMORS. 753 

Such a discharge continuing for a length of time as the only symptom 
should arouse a suspicion of the existence of sarcoma. It is true that 
discharges of this character are not rare as a symptom of submucous 
fibroids, but its occurrence after the menopause is an almost positive 
indication of sarcoma. In the first stage there is no disagreeable odor 
beyond the stale sweetish smell, but with the destruction of the new 
formation the discharge becomes purulent, sanious, and has a foul odor. 
The carrion-like smell so characteristic of cancer is not usually present, 
because the large collections in the uterus are retained by the obstruc- 
tion, and, owing to the arrangement of the vessels, are afforded better 
nutrition, so that the new structures do not so easily break down. The 
disease generally appears in the polypoid form. Sanious discharge 
occurs when the uterus forces the new-growth out, the os is dilated, and 
the diseased mass is extruded into the vagina. The extruded parts 
are to some degree deprived of nutrition, and this results in further 
destruction. The discharge in the vagina has abundant opportunity for 
exposure to infection from saprophytes, which accelerate the rapidity 
of destruction. It is then mixed with ulcerative pieces of tissue, which 
often are thrown off in large masses, and these still further disintegrate 
in the vagina. A bloody discharge will follow and pyometra may 
occur, but this never attains the same extent as the hematometra. Pain 
is absent at the beginning of the attack, but is aggravated with the increase 
in the size of the uterus, the persistent pressure in the pelvis, and the 
sensation of fullness in the abdomen. As the uterus becomes enlarged, 
pain is referred to the ilium or to the sacrum and radiates down the thighs. 
The extension of pain is due to the involvement of the uterine nerve- 
endings by the new formation. Pain is greatly aggravated when the 
disease has passed beyond the boundaries of the organ and infiltrated 
the pelvic tissues and made pressure upon the large nerve-trunks. In 
the polypoid variety the pain becomes labor-like when the structure 
attains a size which leads the uterus to expel it. Painful attacks do not 
occur at such regular hours as in carcinoma. Inversion of the uterus has 
been caused by the efforts of the organ to expel its contents. Vesical symp- 
toms are comparatively frequent when the disease is confined to the uterus 
and are manifested by more frequent desire to urinate, pain in evacuation, 
and distressing vesical tenesmus. These symptoms are more particularly 
seen in the circumscribed variety and are, consequently, not the result 
alone of increased weight. In advanced stages constipation is marked 
from pressure of the infiltrate upon the rectum and partly from decreased 
nutrition. Such patients apply for relief from constipation and the pain 
at stool. The infiltration of the uterus can attain to considerable dimen- 
sions, but, unlike carcinoma, shows but little inclination to compress or 
involve the ureter. As the cervix rarely is involved, vesical and rectal 
fistulae are infrequent. The constant drain will necessarily affect the 
general health, and the cachexia is greater than in cancer. In sarcoma 
of the uterine walls, frequently known as fibrosarcoma, the great diversity 
of symptoms depends upon the situation of the disease, and makes it 
impossible to present a clinical history, as in other forms of trouble. 
48 



754 GYNECOLOGY. 

However, one of the first signs is an irregular bleeding, following the 
menopause, in a woman who has had a myoma. The myoma rarely 
delays the climacteric longer than the fifty-fifth year. The continuation 
of the menses at an advanced age or their return after ceasing should 
indicate the probable degeneration of an existing myoma. Following the 
climacteric, the myoma ordinarily ceases to grow or decreases in size, 
while a sarcoma of the uterine wall increases. A rapid growth subsequent 
to the climacteric is with rare exceptions an indication of sarcomatous 
degeneration of a myoma. A symptom constant in sarcoma and always 
absent in myoma is a premature and rapid cachexia. From great loss of 
blood the myoma may cause anemia, but the sarcoma causes emaciation. 
When the cachexia occurs without much loss of blood, it indicates an 
unfavorable influence upon the blood composition and formation. The 
cachexia is preceded by a sense of weariness, pain in the head, nausea, 
sleepiness, and universal pain throughout the body. Furthermore, 
there is a sensation of tension in the belly without marked increase in the 
tumor. Difficulty in urination without compression is also present, 
and disturbance of nutrition without other assignable cause is quite 
marked. A profuse watery mucous or watery bloody discharge occurs 
similar to that from an ulcerating submucous myoma, except that in the 
latter the growth is not discharged in pieces, but the tumor retains its 
integrity and disintegrates from the surface, while in sarcoma large por- 
tions of the mass are thrown off or are easily broken off by the hand. 
Pain is produced when the disease breaks through the walls of the uterus 
and undergoes great extension. Labor-like pains are caused if the 
•uterus attempts to discharge its contents. Sarcoma occurs in but a small 
percentage of cases of myoma, yet sufficiently often to justify its being 
reckoned as a factor. While the possibility of this degeneration is no 
indication that every patient suffering from myoma should be subjected 
to an operation, still it is a warning which should awaken suspicion when 
adverse symptoms develop in the tissue thus affected. Paget described 
a peculiar form of this disease under the designation of recurrent fibroids. 
Whether in these cases successive mucous fibroids were discharged or the 
condition was sarcoma from the beginning only the microscope could have 
determined. Schroder made a vaginal extirpation in a patient from 
whom he had removed seven successive polypi, the last three of which 
were sarcomatous. The removal of sarcomatous growth long years 
after previous removal of fibroids does not prove that the former were 
malignant. The possibility of such changes occurring in tumors should 
be decided by more frequent examinations of removed growths by the 
microscope, in order that extirpation may be resorted to promptly when 
malignancy is demonstrated. 

It is asserted that metastasis is late in its occurrence in fibrosarcoma. 
This assertion is correct only as to the length of time symptoms exist 
prior to such manifestations, but does not indicate the long existence of 
sarcoma. 

The duration of sarcoma of the cervix is about one and one-half years, 
about the same as that of cancer of the part. It is more difficult to fix the 



PUERPEILA.L TUMORS. 755 

term of the disease in the variety involving the uterine mucous membrane, 
as the earlier symptoms do not come under the observation of the physician. 
Cases have been reported as having survived several years; the average 
duration, however, is about two years. The polypus is slower in its pro- 
gress, probably dependent upon a slighter inclination of this form to invade 
the muscle wall. Metastases occur in about one-fourth the cases and affect 
any tissue in the body. The structures most frequently affected are the 
lungs, peritoneum, lymph-glands, and intestines. In the cervical variety 
it is likely to extend to the vagina, where the involvement is superficial 
and does not interfere with cure if extirpation of the uterus is performed, 
provided the operation is done early. To afford hope of recovery the 
diagnosis must be made early, and not after the recurrence of the disease 
following curetment or amputation of the cervix has demonstrated its 
malignant character. The polypoid growths from the cervix should 
be recognized by their peculiar appearance, and the microscopic examina- 
tion of the cureted scrapings should render the diagnosis certain. The 
reformation of the polypus should lead to the suspicion of malignancy, 
and a careful microscopic examination should be made to determine its 
true character. In the fibrosarcoma it is still more difficult to fix the dura- 
tion of the disease, as we have no means of knowing when the degeneration 
of the fibroid begins. Cases have been reported in which tumors existed 
for ten years. These are probably cases in which the myoma has existed 
for a long period and only in the later years become malignant. Meta- 
stases in this form appear late, follow the course of the blood-vessels, 
and, like the other forms of the disease, involve the lungs, pleura, liver, 
rectum, omentum, and kidneys. Fibrosarcoma is frequently regarded as 
a compamtively benign tumor, because it remains proportionately 
limited to the uterine cavity, but this is incorrect, for this property is 
common to mucous membrane sarcoma and cancer of the body of the 
uterus as well. If metastasis is any criterion as to malignancy, we must 
regard parenchymatous sarcoma as more malignant than the mucous, 
for in the latter metastases occur in only one-fourth of the cases, while 
in the former but one-fourth escape. Although it is impossible to fix the 
duration of life, it would seem to be longer than in the other forms of 
malignant disease. Its progress is attended with the same symptoms 
as in other forms of malignancy. Its termination is usually death from 
exhaustion, bleeding, and discharge, and by the further extension of the 
disease into the various parts of the body. Sepsis plays a less important 
part than in the mucous variety, and ulceration does not appear so fre- 
quently, and, when present, by the evacuation of the ulcerating mass does 
not usually cause general symptoms, though a purulent peritonitis has 
been frequently reported as a cause of death. 

Diagnosis. Sarcoma of the mucous membrane can be 'determined 
accurately by microscopic examination only. Other means will be 
sufficient to render certain the existence of malignant disease, but the 
variety is determined only by the microscope. Neither the condition 
nor symptoms offer anything characteristic of sarcoma, while a majority 
of the diseases of the uterus afford similar symptoms. 



756 



GYNECOLOGY. 



An elderly woman with a large uterus, who suffers from a profuse 
watery discharge mixed with blood, should be suspected of having sarcoma. 
Submucous myoma sometimes causes a similar discharge, but the uterus 
is greatly enlarged, and it does not occur for the first time in advanced age, 
and is always accompanied by bleeding. 

Senile endometritis may cause a profuse discharge, but the discharge 
is purulent, and generally has a disagreeable odor. The organ presents 
the characteristic changes of old age, and is not large. 




Fig. 550. — Fibroma Undergoing Sarcomatous Change. 



A second suspicious sign is vesical tenesmus, which should be re- 
garded as an indication of malignant disease when no other cause exists. 

Sarcoma of the uterine body is naturally difficult to diagnose. It can 
be covered completely by the cervix and the vaginal portion, and when a 
large caulifiower-like mass projects from the cervix, it may be either 
sarcoma or cancer, and the microscope only can determine which. In the 
differential diagnosis there are a variety of diseases which must make the 
diagnosis uncertain. 

The uterine body is always enlarged, but does not differ essentially 
from the enlargement of chronic metritis, myoma, and carcinoma. The 
sarcomatous uterus is not so hard as the myomatous organ. In malig- 



PUERPERLA TUMORS. 757 

nant disease the much enlarged organ indicates sarcoma, but the carci- 
noma may be superimposed upon a myomatous uterus. In the latter the 
form of the uterus is irregular. 

Fungous endometritis, a mucous polypus, and submucous fibroid 
may require the use of the microscope to differentiate them. Positive 
proof of malignant disease is not obtainable by the touch. A sensation 
of softness is common to mucous polypi, submucous myoma, and mucous 
membrane sarcoma. Pieces of the latter can be broken off with the finger, 
as also from other growths when ulcerating. Touch with the finger is 
not always free from danger. It will be safer to employ the microscope 
upon the scrapings obtained by curetment. 

The inexperienced investigator may be confused by the resemblance 
between sarcoma and interstitial endometritis, with more or less destruction 
of the glands. In doubtful cases examine all the parts removed before 
making the decision that malignant disease does not exist, and, if then in 
doubt, keep the patient under close observation. If she continues to 
bleed, make a second curetment, and again examine the scrapings. 

The abundance and variety of the cells in a specimen are of signifi- 
cance in the diagnosis of sarcoma. In round-cell sarcoma the cells are 
round and thick, and exceed in size those of the intermediate tissue, in 
which are found irregular cells. Kellar places particular stress upon the 
fact that the individual nucleus is differently formed and varies in the 
way it accepts the color stain, so that the smaller nuclei are always better 
colored than the larger. When glands are absent, the cells are usually 
pressed together and the epithelium is flattened. If the glands have 
largely decreased in interstitial endometritis, there are distinctive traces 
of connective-tissue formation in the intervening structure, which is 
penetrated in all directions by the migration of connective-tissue cells. 
They differ from spindle cells in that the long axis is drawn out at the ends, 
and the long axis of the nucleus does not fill out the body, while in the 
spindle-cell sarcoma the cells are smaller, plumper, only rarely with 
pointed ends, and the nucleus almost fills out the body. 

The distribution of the vessels is also very significant. In benign 
changes of the endometrium the blood-vessels are few and present dis- 
tinctive walls, while in sarcoma they are more abundant, and appear in 
immediate relation to the surrounding tissue of the growth. Amann 
asserts that the recognition of abundant nuclear division can be employed 
for the diagnosis of sarcoma. 

In the differential diagnosis of subinvolution of the decidua and in- 
complete abortion the clinical history is of advantage ; but if long-continued, 
irregular menstruation is followed by severe hemorrhage, perhaps an 
offensive discharge, while the uterus remains large and not especially 
hard, confusion with sarcoma is possible. This will require the micro- 
scope for confirmation, and then not always with certainty. The indi- 
vidual decidual cells closely resemble those of sarcoma of the mucous mem- 
brane. The retained tissue glands will present the alterations of preg- 
nancy in their epithelium to such a degree that the error is easily avoided. 
The difl&culty will be greater when a retrogression of the decidua has 



75^ GYNECOLOGY. 

occurred, for the uniform structure of the decidua is destroyed. In 
single sections, however, individual islands of the decidual structure 
will be found, while other sections will show a great irregularity in the 
cells. The size of the cells is quite variable; frequently the decidual 
cells show a pronounced spindle shape, and penetration of the tissues 
by round cells exists, so that a structure is formed which is extraordinarily 
like a sarcoma. Differentiation is easily accomplished in such cases by 
demonstrating the chorionic villi. If we find the decidual cells by curet- 
ment of a woman who has had an abortion months before, we will also 
find the chorionic villi present, for the decidual cells are not otherwise so 
long retained. In the absence of the chorionic villi the diagnosis is fixed 
by finding, near the large decidual cells, sections of tissue which show 
the unaltered mucous membrane with retained glands or with the recog- 
nizable alterations of interstitial endometritis. 

Tuberculosis of the endometrium, by the premature loss of the glands, 
through the appearance of numerous round cells in the tissue and the 
occurrence of irritation cells, causes confusion with sarcoma. The 
clinical history, the demonstration of caseation, the peculiar irritation 
cells of tuberculosis, and the rarely demonstrated tubercle bacilli will 
protect against confusion. 

Carcinoma of the Uterine Body. There are certain forms of cancer 
which cannot be distinguished microscopically from sarcoma. We can, 
however, determine that malignancy is present. 

As in the mucous sarcoma, the diagnosis is made only by microscopic 
examination of the discharged or removed pieces of the growth. Greater 
difficulties are experienced in securing the material for study than in the 
latter. A suspicion that fibrosarcoma exists should be awakened: 

First, if a myomatous tumor does not cease to grow after the menopause. 
Rapid growth does not always follow sarcomatous degeneration. 

Second, if a woman with a myomatous tumor commences to bleed 
after the menopause. In rare cases this may occur in advanced age 
from mucous polypi, but the association of a profuse watery discharge 
should be held to be very suspicious of sarcoma. 

Third, if with a myomatous tumor cachexia occurs. Through ex- 
cessive bleeding myoma causes anemia, but never cachexia. 

Fourth, if a myomatous tumor occasions symptoms which are explain- 
able neither by the size nor the situation of the tumor. 

Fifth, if ascites complicates the tumor. The possibility of its being 
caused by other conditions must be excluded. Ascites occurs from pene- 
tration of the peritoneum by the disease, and may follow a subserous 
tumor which has become sarcomatous. 

Sixth, if a myoma which was previously hard grows rapidly and be- 
comes soft and swollen. 

Seventh, if after the removal of a fibrous polypus another follows. 

Recurrence. The tendency of the disease to return seems even greater 
in the fibrosarcoma than in the mucous growth. It is probable that the 
explanation of the greater frequency of the occurrence in the former is 
due to the early recognition and more prompt treatment of the latter. 



PUERPERAL TUMORS. 759 

When a case of mixed sarcoma remains a year free from recurrence it 
may be considered as cured, but not so the fibrosarcoma, for it has been 
known to return at a much later date. The great difficulty in the treat- 
ment of this, as in all malignant disease, is the impossibility of determining 
the diagnosis before the disease has extended beyond the point at which 
it can be removed surely. Results must continue bad until both patient 
and physician have learned to realize that uterine hemorrhage is a symp- 
tom which demands prompt and thorough investigation. When the 
disease has so extended that a radical procedure is no longer indicated, 
our efforts should be directed to the arrest of hemorrhage, the decrease 
of discharge, and the improvement of the general condition of the patient. 

Treatment. Whenever possible, the uterus should be extirpated. 
No other measures are worthy of consideration, but the case must come 
under observation sufficiently early to admit of the extirpation of the 
organ within the limits of healthy tissue. 

Operation is contra-indicated when the disease has so broken down 
the system of the patient that she will be unable to endure the ordeal of a 
radical procedure. It is also contra-indicated when the growth is no longer 
confined to the uterus. The existence of metastases and the extension of 
the disease beyond the confines of the uterus would render operation of no 
avail. This assertion does not apply to extension upon the vagina if the 
disease can be removed. The existence of ascites must not influence 
against the procedure unless the involvement of the retroperitoneal 
glands can be demonstrated. The removal of the entire uterus, even 
in slight cases, is indicated, because it affords greater immunity against 
return than any partial operation. When the size of the uterus permits, 
the operation should be performed by the vagina. This usually can be 
done in cases of mucous sarcoma, as the organ is rarely of large size. 
A fibrosarcoma often may be scraped out and the size of the organ re- 
duced by the administration of ergot for a few days, and the vaginal opera- 
tion performed then. It is unwise to subject the healthy tissues to in- 
fection by cutting up the tumor to reduce its size. 

333. Treatment Following Operations for Malignant Disease. 
The after-treatment of such patients will have been greatly simplified 
by judicious care during and preceding the operation. This care includes 
thorough sweeping out of the intestinal canal with saline purges, the ad- 
ministration of intestinal antiseptics, as salol or the sulphocarbolates, a 
restricted diet from which milk has been excluded, the exclusion of every 
possible means of infection by cleansing the patient, and during the ope- 
rative procedure the employment of measures to sustain the circulation. 
Immediately following the operation the patient should be under the care 
of a conscientious nurse, who will see that she is kept properly covered 
in a well-ventilated room. Where necessary, the bodily temperature 
should be maintained by artificial means, such as hot blankets and hot- 
water bottles. Do not allow this to drift into a routine procedure to be 
employed regardless of conditions, as, for example, after a difficult opera- 
tion, upon a very hot day, following the patient to her room, I found her 
covered with blankets and surrounded with hot bottles; upon taking her 



760 GYNECOLOGY. 

temperature it was found to be 104° F. Obviously this patient was get- 
ting the opposite of what she should have had. The patient, unless very 
feeble, should not be confined to one position, but should be permitted 
to move from side to side. The pulse, temperature, and general appear- 
ance of the patient should be watched carefully for danger signals. Where 
the patient is uncomfortable and unable to evacuate the urine, it may be 
drawn by catheter, but catheterization should be avoided, where possible, 
and need not be employed under sixteen hours unless the patient com- 
plains of distress. For the general principles of after-treatment the 
reader is referred to §150-164, as only details especially referable to 
operations for malignant disease will be here discussed. 

If the abdominal wound is closed, the vaginal tampon of gauze may 
be permitted to remain for six to nine days. In the third week the patient 
is permitted to arise, and in the fourth to go about the house. When 
clamps are used instead of ligatures, the weight and dragging of these 
instruments increase the pain. The distress is aggravated by every move- 
ment, and frequently morphin may be required to make it endurable. 
The difficulty often is increased as early as the day after the operation by 
an accumulation of flatus. In the majority of cases the difficulty appears 
later, and is relieved only after prolonged rectal irrigation. The mete- 
orism, increased abdominal sensibility, enhanced rapidity of pulse, and 
elevation of temperature produce anxiety, which is aggravated by pro- 
longed vomiting and other signs of ileus. A number of cases are reported 
of a fatal result from kinking of the intestine. The continuation of such 
symptoms should lead to removal of the gauze, for fear that it is causing 
the obstruction. This is done with the recognition of the fact that the 
adhesions are not firm, and that trouble may arise from its premature 
removal. The cavity should be tamponed lightly. In the removal of 
the gauze care must be exercised that a knuckle of intestine is not drawn 
into the vagina. Such an accident occurred in one of my patients, where 
the interne withdrew the gauze and found that there was a large coil of 
intestine in the vagina, which he could not replace. I placed the patient 
upon her side, with the hips elevated, and had no difficulty in replacing 
the intestine, which was kept in place by a gauze tampon. As to how long 
the gauze shall remain, operators differ — from the one or two days of 
Doyen to the ten days of Zweifel. The latter prefers the longer period 
because the earlier removal of the gauze breaks up the adhesions and 
draws down the intestines; at the later period the gauze has become 
loosened and the intestinal adhesions are so firm that they are undisturbed. 

The clamps are generally removed at the end of forty-eight hours. 
Landau and Seligman remove them on the second day. I have had 
several cases of severe hemorrhage after removal at the end of forty- 
eight hours — hemorrhage which is difficult to control. Its occurrence 
requires resort to exposure of the cavity by retractors, and the ligament 
must be followed up and the bleeding vessels again secured with forceps. 

Another objection to the use of clamps is the danger of injury to the 
ureter and the bladder, but this is due to want of care in pushing away 
these organs, and is just as likely to occur from careless use of the ligature. 



FALLOPIAN TUBES. 761 

Injuries of the rectum are also reported, but are less excusable than those 
of the urinary apparatus. Among the causes of fatal result sepsis is the 
most frequent. 

FALLOPIAN TUBES. 

334. Benign tumors or growths of the Fallopian tubes are 

exceedingly rare, except as a result of inflammatory disturbance. 

Fibroma or myoma is infrequent and of small size. It develops from 
the muscular tissue of the tube, and may grow inward or become sub- 
peritoneal, but rarely obstructs the tube lumen. Inflammatory and tuber- 
culous alterations have been mistaken for myoma, particularly the con- 
dition known as salpingitis nodosa. Under the name of adenomyoma 
or cystadenoma Recklinghausen describes a peculiar form of myoma 
which occurs only in the uterus and tube. It is characterized by the 
usual constituents of the fibroid, which include glandular structure. In 
the tube he attributes it to some remains of the primordial structure — 
the Wolffian body. 

Fibrocyst, a unique new formation, is described by Sanger-Barth. It 
consists of three tumors collected from a conglomeration of various large 
cysts and firm tumors that were in part pedunculated from the fimbria 
of an otherwise healthy tube. Microscopically, the wall of the cyst con- 
sisted of fibrous connective tissue with smooth muscle-fiber, and within 
a nest of embryonic tissue. Its surface was covered with ciliated epithe- 
lium, and the contents of the cyst were detritus. The principal mass of 
firm tissue partly consisted of gelatinous myxomatous and partly of loose 
cell tissue. The products greatly resembled a teratoma. 

Enchondromata are small, semitransparent, cartilaginous masses, 
which are occasionally situated upon the ends of the fimbriae. 

Dermoid of the tube is exceedingly rare. Ritchie describes a plum- 
sized bone removed from a dermoid of the tube. Pozzi, in a recent edition 
of his work, presents a diagram of a dermoid cyst removed from the tubal 
wall, which was adherent to the ovary. It had developed within the tube 
and ulcerated through the overlying wall. 

Cysts of small size are frequent, though their true cystic character is 
denied. The large irregular bullae so common in association with fibroid 
growths are said to be dilated lymph-spaces. Cysts varying from the size 
of a pea to that of a walnut are found in all the walls of the tube, but most 
frequently beneath the peritoneum. Cysts within the tube are not infre- 
quently the result of inflammatory changes by which the adjoining folds 
of the mucous membrane become adherent. Cysts of the tubal fimbriae 
become pedunculated and resemble the hydatid of Morgagni, which is 
by some regarded as a cyst. The cysts contain clear serum, colloid masses, 
or chalky bodies. Sanger divides these cysts into : 

1. Serous cysts, which arise by the accumulation of serous fluid be- 
tween the lamellae of the new mucous membrane. They can attain the 
size of a chfld's head, and may be either single or double. 

2. Lymphangiectasis and lymphangiectatic cysts in three forms: 



762 GYNECOLOGY. 

(a) As small vesicles upon tube and ligament, identical with those of 
older authors; (b) winding, ramifying tubes with constrictions and cystic 
distentions; (c) lymphangiectatic cysts — large, tough- walled, isolated 
cysts in the tubal serous covering or the mesosalpinx. The two latter 
occur especially with uterine myoma. 

3. The hydatid of Morgagni, regarded as a physiologic cyst of the 
end of a tubal fimbria. 

Inflammatory cysts of the tubes — known, from the character of their 
contents, as hydrosalpinx, pyosalpinx, and hematosalpinx — have been 
discussed under inflammation. (§247.) 

Polypus is a rarely recognized growth. Lewers reports a case in 
which, upon the inner surface of each dilated tube, were numerous growths 
varying in size from a pin's head to a pea. Amann speaks of a growth 




Fig. 551. — Papilloma of the Fallopian Tube. 

of the mucous membrane consisting of connective tissue covered with 
enormously folded cylindric epithelium. Rokitansky and Klob describe 
connective-tissue growths of the fimbriae. 

Papillomata, denominated by Sutton as adenomata, are aUied to the 
condylomata, or warts, found upon the vulva. The villus consists 
mainly of epithelium. Sanger has collected six cases, and divides them 
into two forms: (i) Simple cystic; (2) hydropic. 

The simple cystic is an indefinite soft growth from the mucous mem- 
brane, of a cauliflower-like appearance (Fig. 551), and its villous structure 
may fill out the tube and distend it into a considerable sized tumor. 

In the second form (cystic and vesicular papillomata) the tubal end 
becomes closed and the villi are so swollen as to give the appearance of a 
cystic mole. This form differs from the first in the greater size of the 
cavity, from the inner surface of which spring the papillary masses. 
Doran and Sutton have attributed the occurrence of papillomata to pre- 
vious gonorrhea, but with such a cause they should occur more frequently. 
They are difficult to differentiate from sarcoma and cancer. Their 
benignity, however, is proved by the absence of any tendency of their 
epithelium to atypic growth, and there are no metastases. 



FALLOPIAN TUBES. 763 

335. Malignant Tumors. Carcinoma of the tube may be either 
primary or secondary, though the latter is the more frequent. Secondary 
involvement of the tubes from cancer of either the ovaries or the uterus 
is comparatively late, as we frequently find the ovary forming a large 
tumor from cancer or sarcoma without any involvement of the tube. 
Doran divides primary cancer of the tube into two forms: 

1. WTien the cancer develops in the mucous membrane of a normally 
formed tube. 

2. \\Tien it forms in a malformed tube bearing a cyst whose wall be- 
comes infected. 

In the first form its situation shows its origin in the papillary struc- 
ture — whether from degeneration of papilloma, as believed by Doran, or 
directly from the tubal mucous membrane, as asserted by Sanger-Barth, 
remains to be determined. The occurrence of the disease in the middle 
and external portions of the tube indicates that it is a sequel of inflam- 
matory trouble. 

In the second form the disease develops in a cyst of the ostium. 
Doran describes a specimen in which the end of the right tube was dilated 
for an inch and a half, was very tortuous, and formed a tumor an inch in 
diameter at its widest part. In its wall was a solid deposit, over a quarter 
of an inch in thickness. At its outer part it communicated with a thin- 
walled cyst, situated in the anterior part of the broad ligament, lifted 
up its anterior fold, and raised the serous coat of the uterus. The cyst 
was about six inches in diameter, and its interior contained a thick de- 
posit which appeared encephaloid in character. Under the microscope 
the stroma was scanty, with wide alveoli containing great masses of cubic 
epithelial cells, as in encephaloid cancer. 

Amann is inclined to believe that cancer of the tube will prove to have 
developed through metastases from the uterus. Taussig reports a case 
of cancer of the cervix in which a metastasis to the tube had occurred 
without any intermediate movement. The disease is generally confined 
to one tube. The recognition of its existence is necessarily difficult. 
When, after previous pelvic inflammation, a patient who has reached her 
forty-fifth year shows a sudden or steady growth of subjective and ob- 
jective symptoms, cancer, says Doran, may be suspected, and watery 
or sanious discharges greatly increase the suspicion of malignancy. 

Treatment should consist in the prompt removal of all infected struc- 
tures. 

Sarcoma of the ovary is frequent; of the tube, very rare. Occasionally, 
the sarcomatous nodules are found scattered over the peritoneal surface 
of the tube, but the disease more frequently passes from the ovary to the 
omentum. Kahlden reports a case in a woman of fifty-one years, in 
which the tube formed a sausage-shaped mass filled with soft, cauliflower- 
like material. Under the microscope it showed various degenerations, 
such as round-cell and spindle-cell sarcoma, and a papillary structure 
wanting in connective tissue. These formations were found to arise 
from the endothelium of the lymph-vessels, which was increased several 



764 GYNECOLOGY. 

layers. As important constituents could be shown irritation cells similar 
to those in sarcoma. 

Chorio-epithelioma Malignum. Just as malignant degeneration can 
occur in a portion of placenta or chorion which is retained in the uterus 
and produce a large tumor and subsequent metastatic deposits in the 
abdominal and thoracic viscera, a similar malignant change may follow 
an ectopic gestation in the tubal sac. Sanger advances this as an ad- 
ditional argument for active interference in such cases, and for the ex- 
tirpation of tubal moles and of the appendages when tubal abortion has 
occurred. 

THE BROAD LIGAMENT. 

336. Cysts of the broad ligament varying in size from a pea to a 
pigeon's tgg are frequent, and generally of little clinical interest. They 
may be situated upon the surface of the ligament or may lie deeply within 




Fig. 552. — Broad Ligament Cyst. 
T. Fallopian Tube. P. Parovarium. O. Ovary. 

its folds. Their walls are thin and the contents of the cyst consist of a 
watery or pale colored fluid. Superficial cysts are of undetermined origin, 
while the deeper growths are attributed to changes in the parovarium. I 
recently removed a multilocular cyst from the anterior surface of the broad 
ligament by opening the overlying peritoneum and enucleating the cyst. 
The ovary was not affected and was left undisturbed. These cysts are 
frequently pedunculated, but rarely attain to any great size. They are 
generally called microcysts, and often are developed in the structure or 
suspended from the organ of Rosenmiiller. Only those which develop 
from the vertical tubes of the parovarium have ciliated epithelium and 
are liable to form papillary growths subsequently. 

Parovarian Cysts. (§342.) 

Echinococcus cysts are rare, except in certain districts, notably Iceland 



THE BROAD LIGAMENT. 765 

and Mecklenburg. In the majority of cases they occur primarily in the 
pelvic connective tissue, and always near the intestine. In rare instances 
the ovary proves to be the primary seat of the disease. The wandering 
of the parasite causes a chronic inflammation, characterized by round, 
elastic tumors situated near the rectum, which are slightly movable, but 
not painful. Bimanual palpation reveals that they are not connected with 
the uterus or ovaries. A positive diagnosis is to be determined only 
by a careful examination of the fluid obtained from the cysts, either by 
spontaneous rupture or by puncture. The danger of infection from it is 
so great that the certain determination of the disorder will not compensate 
for the increased peril induced by the puncture. 

Treatment. The proper plan of treatment consists, when possible, in 
the removal of the sac. If we are unable to remove the cyst completely, 




Fig. 553. — Broad Ligament Cyst, with Torsion of Its Pedicle. 

it should be fastened to the abdominal wall and drained. Pozzi advocates, 
when we have had to open the peritoneal cavity, that the opening over 
the cyst should be packed with iodoform gauze for twenty-four to forty- 
eight hours, until adhesions have formed, before the cyst is opened. 
It can be done then without danger of infecting the peritoneal cavity. 
If the tumor is situated low in the pelvis, a vaginal incision should be pre- 
ferred. The sac cavity should be emptied and packed with gauze. 

Parovarian Varicocele; Phleboliths. A varicose dilatation of the veins 
of the pelvis is common, and frequently, according to Klob, results in the 
formation of phleboliths. Their frequent occurrence is attributed to the 
unusual existence of valves in the veins of the broad ligament. These 
masses attain the size of a pea or bean, and occasionally cause inflam- 
mation and thrombus formation. When situated so that they can be pal- 
pated through the vagina, they are often mistaken for ureteral calculi. 

Lipomata. Small collections of fat are not infrequently found in the 
mesosalpinx of the broad ligament near the under surface of the tube. 
They can attain the size of a bean, occasionally the size of a walnut. 



765 GYNECOLOGY. 

Fibroma. As the same muscular structure is found in the broad 
ligament as in the uterus, it is not surprising that occasionally fibroids 
should be found in the ligament independent of the uterus and its structure. 
Such growths may spring from the round ligament or are found in the 
broad ligament. The latter have been considered as aberrant uterine 
fibroids which have become separated from their first attachment. Sanger 
found these growths most frequently upon the right side. They may be 
situated intraperitoneally, in the fold of the groin, or in the labium majus. 
The mass may have a pedicle or may be sessile. It does not attain a 
large size, is quite movable, and is not painful. The condition may be 
confounded with fatty hernia, an epiplocele, or an ovarian hernia. 
The fatty hernia is frequently reducible, painful to the touch, quite soft, 
and ill defined. The irreducible epiplocele becomes like a fibroid, but 
has a cord stretched behind the abdominal wall. In an ovarian hernia 
the tumor retains the shape of the organ, is exceedingly sensitive, and 
increases at each menstrual period, while the uterus is displaced to one 
side. The treatment is extirpation. 

337. Malignant Growths. Carcinoma and sarcoma of the broad 
ligaments are usually the result of extension of the disease from the uterus 
or ovaries. The rectum, the bladder, or the retroperitoneal glands 
may be the source of the infection. 

OVARIAN TUMORS. 

338. Ovarian Tumors. Characteristics. Tumors of the ovaries 
differ from neoplasms of the other portions of the genital tract in their 
greater propensity to malignant degeneration, often rendering it difficult 
to determine whether an individual growth is malignant or benign. 
For this reason we will depart from the custom we have followed 
previously and discuss the two classes of tumors together. 

Classification. The tumors of the ovary are divided: 

[ Simple. 

[ Cystic <! Proliferating. 

I [ Dermoid. 

Clinically { f Fibromata. 

c 1- 1 J Sarcomata, 
bona { r^ • 

Carcmomata. 



Endotheliomata. 
f Simple. 

Pathologically \ Proliferating. 

■ Dermoid. 

[ Parovarian, 

According to size / Small. 

1 Large. 

Cysts may originate in any part of the tubo-ovarian structure, as the 
cortical, medullary, or parenchymatous portions of the ovary; in the 
structure between the tube and ovary known as the Rosenmiiller organ 
or parovarian structures; and in the hydatid of Morgagni, the extremity 
of the canal of Mliller. We have already spoken of cysts which develop 



OVARIAN TUMORS. 



767 



in the folds of the broad ligament and are recognized as broad ligament 
cysts. Cystic growths may become of almost unlimited size, larger than 
any other growth of the body, and occasionally the body may seem but 
an appendage of the tumor. These growths repeatedly reach a weight 
of 100 pounds. Maritan reported an ovarian cyst weighing 200 pounds 
removed from a woman who previously weighed 290. (Fig. 554.) Her 
girth measure w^as ninety inches. Bullitt removed a tumor whose sac 
and contents weighed 245 pounds, and Spohn 
pounds with recovery of the patient. 



of Texas, one of 328 




Fig. 554. — Large Ovarian Tumor. 

Solid tumors are much less frequent than the cystic and closely retain 
the shape of the ovary. The cystic are irregularly spheric — the more 
spheric, the larger they become. As a rule, the surface is a bluish-white, 
greenish, brownish, yellow, or a ghstening white. Secondary developments 
may occur in the wall, giving it an irregular shape, or it may consist of a 
large number of small cysts, which give the impression of a solid tumor. 

Cysts are still further divided into unilocular or single cysts, and multi- 
locular, where the sac is composed of a number of cavities or smaller cysts. 



768 GYNECOLOGY. 

Careful examination of a unilocular cyst will frequently show smaller 
cysts within its walls. 

The contents of the various tumors greatly differ; indeed, the different 
cysts in the same tumor show radically different contents. In the uni- 
locular tumors the contents are usually clear and limpid; in the multilo- 
cular, thick, viscid, and glue-like in some, clear and limpid in others, 
while, from various causes, there may be discoloration by an admixture 
of blood, pus, or fat. 

The broad ligament cysts are generally unilocular and contain a clear 
fluid; those which originate in the hilum are papillary; and those from 
the parenchymatous structure of the ovary, glandular. 

The small cysts comprise: 

Small residual cysts. 
Follicular cysts. 
Cysts of the corpus luteum. 
Tubo-ovarian cysts. 
The large cysts are : 
Glandular proliferous. 
Papillary proliferous. 
Dermoid. 

f Hyaline. 
Parovarian. { Papillary. 

[ Dermoid. 

Small residual cysts are growths which develop in the structure between 
the tube and ovary, known as the parovarian structure, or the organ of 
Rosenmiiller. Those which develop in the vertical tubes have ciliated 




Fig. 555. — Small Residual Cysts. 

epithelium, and may develop subsequently into papillary growths. 
They may become detached from the ligament and hang from the perito- 
neal surface by a slender pedicle. It is possible that from these cysts may 
originate large cysts filled with either fluid or papillary contents. 

Attached to the fimbriated end of the tube generally is found a small 
cyst, varying in size from a pea to a cherry, known as the hydatid of 



OVARIAN TUMORS. 



769 



Morgagni, which, from its almost continuous presence, is regarded as 
a physiologic cyst. This hydatid is the termination of the duct of 
Miiller. It is transparent, has a thin wall, and has a pedicle often 
a full inch in length. Doran describes a supratubal cyst of similar size, 
appearance, and structure, which he supposes to be a microcyst of the 
broad ligament in this anomalous position. 

Simple or Follicular Cysts; Hydrops Folliadorum. These cysts are 
unilocular dilated follicles, generally multiple and small. In an ovary 
that has not attained to twice its normal size fifteen to twenty of these 
cysts^may be found. WTien small, the ovary is but slightly enlarged and 




Fig. 556. — C3"st of the Corpus Luteum. 



the foUicle^projects upon the surface or lies embedded in the stroma. 
These cysts were long considered the sole source of large ovarian cysts, 
but it is only in rare instances that they attain the size of a fist, occasion- 
ally of a man's head. The contents of the cyst are generally clear, but 
may be blood-stained, and have a specific gravity of from 1005 to 1020. 
The cyst-wall is a transparent, thin membrane of a light gray color, 
covered with columnar epithelium. The cysts may be few and the stroma 
excessive, or the former may be very numerous and the latter scanty. 
When the latter condition is present, the ovary is frequently converted 
into a mass of delicate cysts. It is not unusual to find an otherwise 
49 



770 



GYNECOLOGY. 



healthy ovary containing a unilocular cyst the size of a hen's egg. The 
disease is generally bilateral. 

Etiology. These cysts, even when large, are regarded as unruptured 
and dilated Graafian follicles, because of the gradations observed between 
them and the smaller cysts. In the smaller ones ovula may be detected, 
which have been destroyed or have escaped observation in the larger. 
Failure to rupture and increase of the fluid contents produce a dropsy 
of the follicle. The normal rupture may be prevented by undue thickness 
or toughness of the walls, the result of inflammation; by deposits of ex- 
udation over the surface of the ovary; or by the deep situation of the devel- 
oping follicle; or failure may be the result of too slight congestion, 
which, though increasing the secretion, is too gradual to produce rupture. 
Such cysts have preceded menstruation, being occasionally found in 
the fetal ovary. As these cysts are generally associated with chronic 
oophoritis and thickened tunica albuginea, they are generally associated 
with sterility, excessive menstruation and pain preceding the menstrual 
flow from ten days to two weeks. 




Fig. 557. — Tubo-ovarian Cysts. 

Cysts of the Corpus Luteum. These are unilocular cysts the size of a 
pigeon's egg, occasionally as large as an apple. They were first described 
by Rokitansky, who believed that only the corpus luteum of pregnancy 
could be thus transformed, but such cysts have been found in nulliparae. 
(Fig. 556.) The cyst-wafl is comparatively thick, lined by a yellow, ap- 
parently folded membrane, in which microscopic examination shows the 
bud-like papillae characteristic of the corpus luteum. The recognition of 
this structure prevents their confusion with follicular cysts, or even with 
suppurative ovaritis. 

Tubo-ovarian Cysts. An ovarian cyst in contact with a distended 
tube not infrequently results in the formation of a tubo-ovarian cyst. 
(Fig. 557.) The tubal inflammation early causes the formation of exten- 
sive adhesions fixing the tubal ostium to the ovary. The increasing 
pressure of the accumulating fluid gradually absorbs the thin septum 
until the two sacs form one cavity, the smaller portion of which usually 
is formed by the tube. It does not generally attain a large size. The 



OVARIAN TUMORS. 



771 



uterine end of the tube may remain permeable, and, as the fluid 
increases, permits the excess to drain through the uterus, forming a 
condition known as profluent tubo-ovarian hydrops. It resembles the 
condition engendered in hydrosalpinx, known as hydrops tuhce. prqfluens. 
The open tube acts as a safety-valve, preventing the increase and over- 
distention of the cyst, frequently leading to its complete collapse after 
every evacuation. 




Fig. 558. — Large Ovarian Cyst. Patient Upright 



339. Glandular Proliferating Cyst. This class of cysts comprises 
the great majority of ovarian tumors, and they vary from the size of an 
egg to that of a tumor weighing over two hundred pounds, which may fill up 
the entire abdomen and encroach upon the thoracic viscera. The surface 
of the cyst presents a pearly- white, glistening appearance, the thinner 
portions of which are purple, green, or black, according to the color of 
their individual contents. The external surface may be smooth, oily^ 



772 



GYNECOLOGY. 



and covered with papillary growths or mucous vegetations. (Figs. 558 
and 559.) 

The term proliferous is applied to those which are highly organized 
and abundantly supplied with blood-vessels. The term proligerous 
is given to cysts that have the faculty of budding or generating new cysts 




Fig. 559. — Ovarian Cyst. Patient Recumbent. 

from or within the original growth. They may be spheric in shape and 
regular in outline, simulating a single cyst, or may be irregular from the 
numerous nodules, indicating the presence of a multilocular tumor. 
These growths generally have a distinct pedicle. 

The attachment of the tumor may be pedunculated or sessile. The 




Fig. 560. — Pedicle of an Ovarian Cyst. 

latter are frequently intraligamentary. The pedicle may be long or short, 
thin and band-like, or broad and thick. It is developed by the traction 
of the tumor and the resulting hyperplasia of the ovarian ligament, 
and by stretching of the meso-ovarium, of the side of the broad ligament, 
.and of the suspensory ligament of the ovary. The tube generally remains 



OVARIAN TUMORS. 



773 



separated from the tumor by its mesosalpinx, though the ampulla is often 
fastened to or approaches the tumor, because of the strongly drawn in- 
fundibular ovarian ligament, and the tube usually is elongated. In 
ovariotomy the tube generally is removed with the pedicle. After the re- 
moval of the tumor the cut surface presents a triangular appearance, in 
which the angles are pointed or blunt, small or large, and formed by the 
stump of the ovarian ligament, the transverse section of the tube, and the 
stump of the spermatic artery. The pedicle consists of smooth muscle- 
fibers, connective tissue, and hypertrophied blood-vessels. 

The pedicle varies in length from four to twenty centimeters; in 
breadth, from two to twelve centimeters; and may be entirely absent 




Fig. 561. — Intraligamentary Ovarian Cyst. 

The difference in the development of the pedicle is due, in part, to the 
insertion of the ovary upon the posterior surface of the broad ligament, 
and partly to the origin and growth of the tumor. 

With the ovary originally embedded in the ligament, the development 
of the cyst in its external part will result in the formation of a pedicle; 
but the growth of the cyst toward the hilum may result in the spreading- 
out of the broad ligament and the formation of a subserous cyst. A cyst 
growing outward through the ligament may cause it to split and form two 
pedicles. As a tumor develops inward in an embedded ovary and spreads 
out the ligament, the uterus is pushed to one side, and the tumor fills up 
the side of the pelvis, to displace the pelvic organs in general. Such 
a tumor becomes firmly fixed in the pelvis, pushes the peritoneum from 
the uterus, invades the space between it and the bladder or rectum, and 
frequently partly spreads out the uterus upon its surface. Such growths 
are known as intraligamentary cysts. The cyst may be only partly 
subserous, having spread out the anterior wall of the broad ligament in 
advance of it, so that the inferior surface of the tumor is uncovered by the 



774 



GYNECOLOGY. 



serous membrane. The separation of the posterior leaflet in such a 
growth reveals a long pedicle formed by the anterior fold. As an ovarian 
tumor develops, its increasing weight carries it backward into the retro- 
uterine pouch. It is rarely found in front of the uterus. The subsequent 
development causes it to fill the pelvis gradually until its size no longer 
permits it to remain below the brim, when it rises into the abdomen. 
With the change of position there is a partial rotation of the pedicle, which 
is without clinical significance unless it exceeds a quarter of a circle. 
Occasionally, the withdrawal from the pelvis is retarded by a marked 




Fig. 562. — Positions of ovary which favor pedunculation, absence and 
intraligamentary growth. 



projection of the promontory of the sacrum, a roomy pelvis, or extensive 
adhesions. Such a tumor as it increases in size compresses the pelvic 
viscera, forces the uterus and bladder upward, and may dissect downward 
until it protrudes at the vagina. In a case under my observation, it was 
covered only by the posterior vaginal wall. 

The nonpedunculated tumor, as it progresses, becomes limited by the 
lateral walls of the pelvis, after it has spread out the structure and come 
in contact with the parametrium. In its further growth it is pushed up- 
ward and to the opposite side, carrying the uterus. These changes fre- 
quently displace the sigmoid portion of the colon, placing it above and 



OVARIAN TUMORS. 



775 



in front of the tumor. The intestine is frequently compressed, but not 
sufficiently to close its canal, and the large vessels are often obstructed. 





Fig. 564. — Adenocystoma of Ovary, Showing Papillary Formation. 
a, a. Papillar}^ projections. 

The presence or absence of the pedicle depends somewhat upon the 
variety of the cyst. The glandular incline to a long pedicle, the papillary 
to a short or absent pedicle, and the dermoid to a short, strong pedicle. 



776 GYNECOLOGY. 

Structure. The consideration of the internal structure of the glandular 
cysts justifies their division into areolar, unilocular, and multilocular. 
These glandular cysts, according to Virchow, originate in an invagination 
of the proliferating ovarian epithelium into the stroma. Further invagi- 
nation and proliferation of the tissue result in the formation of new gland 
tubes, from which new cysts form. (Fig. 564.) The continuation of these 
processes results in the formation of the many-chambered glandular or 
adenomatous cyst. Mary A. Dixon- Jones attributes ovarian growths 
to inflammation through which the tissues become embryonal and new- 
growths follow. 

Areolar Cyst. A conglomeration of small cysts with a thick, well- 
developed, and vascular stroma is known as an areolar ovarian cyst. 
A number of these cysts may have ruptured to form a considerable sized 




Fig. 565. — Areolar Ovarian Cyst. 

one, or the tumor may consist of a very large number of small masses, 
none of which will exceed the size of a plum. (Fig. 565.) 

Unilocular cysts often attain an enormous size, but examination dis- 
closes evidences of their previous division into numerous smaller cysts, 
so that we can safely assert that all unilocular cysts have originated from 
the multilocular. The investigation of a large cyst usually will show the 
presence of small cysts in its walls, and not infrequently the remains of 
septa within its cavity. 

Multilocular cysts contain a number of cysts of varying size, so ar- 
ranged as to present the appearance of a single tumor. As these indi- 
vidual sacs increase, their intervening walls gradually become thinned, 
until, one after another, they rupture and the sacs coalesce to form larger 
single chambers. Not infrequently the circumference of the septa re- 
mains, to become still more stretched as the tumor grows, until it forms a 
cord-like thickening upon the inner surface. Occasionally, the vascular 
structure alone remains to indicate the former septum. In sudden rupture 



OVARIAN TUMORS. 777 

the vessels of the septa are torn, producing extensive hemorrhage into the 
sac, which changes the character of the cyst-contents. 

In the principal cyst we usually find a wall of three layers, the outside 
consisting of pure connective tissue, like the albuginea of the ovary. The 
middle layer consists of loose connective tissue with numerous large ves- 
sels, while the inner layer is rich in cells and contains numerous small 
vessels. 

The external surface of the cyst is covered with columnar epithelium, 
which differs from the pavement epithelium of the peritoneum. The 
cysts are lined with a one-layered cylindric epithelium, which presents 
different forms in different tumors, and by its structure governs the charac- 
ter of the secretion in the various sacs. It is only in the smaller sacs, 
however, that the true similarity of the epithelium and secretion is ob- 




FiG. 566. — Unilocular Cyst. 

served. In the larger cysts the epithelium undergoes degenerative 
changes; is flattened by pressure; suffers disturbances of nutrition through 
thinning of the septal wall; and undergoes fatty or albuminous changes, 
which cause the epithelium entirely to disappear from the wall of the 
larger cysts. Epithelial sprouts may remain upon the wall, forming new- 
growths. 

Pfannenstiel directs attention to the possibility of the formation of 
papillary growths in the adenomatous cysts. This formation is of great 
variety, and is found inside as well as upon the surface of the tumor. 
Sometimes these growths are but sparsely distributed upon the inner surface 
of a large cyst; in others they appear as circumscribed tufts upon one side, 
while the remaining portion is smooth; or, again, the entire cavity may 
be filled with strong, branching growths, while the quantity of fluid is 
scanty. The larger the cyst, the greater the probability that a large por- 



778 GYNECOLOGY. 

tion of the wall is smooth. As a rule, the papillae are most marked upon 
the side of the cyst toward the hilum, while the peripheral side will be 
scantily involved, if at all. 

A great variety in the quality of these vegetations exists. At times 
only small wart-like growths, from one to two millimeters high, are scattered 
over the surface, together giving a velvety or grater-like appearance; 
at others, branching growths of various sizes, up to that of an apple, 
which may be either broad-based or with a thin pedicle. All the changes 
are present that are found in the ordinary papillary cyst. The growths 
appear either as reddish, granulating, cauliflower-like projections, 
or as sago-sized masses; rarely in the grape-cluster form. 

Cyst-contents often present great contrasts in their color and consis- 
tency; they may be found almost colorless, straw-colored, milky, green. 




Multilocular Cyst. 



purple, or black in color; thin or thick, viscid or gelatinous in consistency. 
The contents of the various cysts in the same tumor will differ in color 
and consistency. In some the fluid will be thin, and in others so 
viscid that it will not flow. The fluid in the smaller cysts is more consistent, 
and becomes thinner as the cysts increase in size, because of changes in 
the epithelium. 

The specific gravity of the fluid varies from 1002 to 1020, with an 
average of about 1012. However viscid the fluid, it is found absolutely 
structureless. Blood-corpuscles, epithelial cells, and crystals of choles- 
terin are often present. The reaction of the fluid is neutral or alkaline. 
Upon analysis various forms of albumin, as metalbumin, paralbumin, 
and albumin-peptone, are found. 

340. Papillary Proliferous Cysts. Papillary cysts show a marked pro- 
liferation of the connective tissue', which forms itself in tufts upon the inner 



OVARIAN TUMORS. 779 

surface of the tumor, as described above in the complication of the glan- 
dular growths. These branching projections may distend the sac to 
bursting, and these tufts project upon the outside, leading to rapid in- 
fection of the general peritoneum. The vegetations spring up luxuriantly 




Fig. 568. — Small Papillary Ovarian Cyst. 

over the surface of the ovary, are carried to every part of the perito- 
neal cavity, and not infrequently, by the action of the diaphragm, are 
carried to the upper surface of that muscle in the thorax. 

The contact of this infection with the peritoneum rapidly produces 




Papillary Tufts upon Inner Wall of Cyst. 



ascites. Similar vegetations may arise spontaneously from the surface 
of the ovary, and then are known as superficial papillomata. It is prob- 
able that these are cases in which a very small cyst has opened and 
afforded the seed which has infected the external surface. The papillary 



780 GYNECOLOGY. 

tumors rarely attain a large size, and are generally bilateral. The den- 
dritic growths project in every direction, are reddish or pearly white and 
glistening, often three or four inches long, and have the appearance of 
stems of coral. The masses have usually undergone a partial calcification, 
so that they break easily and without bleeding. 

341. Dermoid cysts are growths in which are found skin and 
mucous membrane, together with all the structures generally associated 
with such tissues. The tissues most frequently found are hair, teeth, 
nails, and sebaceous and sweat-glands. Other structures, occasionally 
seen, are the mammae, horn, bone, unstriped muscle-fiber, and rarely, 
tissue resembling brain. Fat or sebaceous material exists in the largest 
quantity, often at the temperature of the body in a liquid state. Occasion- 
ally, it is found in solid balls. In a patient on whom I operated over two 
gallons of fatty bodies the size and shape of peas were evacuated. Sutton 




Fig. 570. — Surfaces of Ovaries Infected with Papillary Vegetations. 

reports finding over three hundred bodies in one sac. Frequently hair 
is present in great abundance, and varies in color, length and quantity. 
It may be blond, brown or black, but the color bears no relation to that 
of the hair of the individual. Teeth are found in about one-half the 
cysts; they may be loose, fixed, or buried in the wall. Section through 
the tooth often reveals it situated in a bony alveolus. Beneath the hard 
crust of the tooth is found a white or reddish-yellow medullary substance. 
We may occasionally find incisors, molars, and premolars in the same 
bone. The number of teeth is often enormous. Schnabel described a 
case which had three pieces of bone and one hundred teeth. Plouquet 
found three hundred teeth. Various bones have been described, as the 
jaw-bone, the petrous portion of the temporal bone, ribs, and the pelvic 
bones. A finger with articulated phalanges, nail, and nail-fold and an 
entire skeleton have been recognized. In a double dermoid removed 
from a girl of eleven years I found a well-formed half of the upper jaw, 
equipped with teeth, alveolar process, and normal mucous membrane. 



OVARIAN TUMORS. 



781 



Dermoids do not always occur alone, but in conjunction with large 
glandular cysts, the dermoid forming but a small part of the mass. 
Sometimes the entire cyst will be found filled with sebaceous material, 
while careful examination, after washing, shows that the skin covers only 
a small part of the mass. 

Teratoma is a more complex form of tumor which 'is usually classed 
with the dermoid. It contains an even more varied structure, and re- 
sembles more the solid growths than the cystic. It often attains an enor- 
mous size, and contains the various structures of the dermoid and carti- 




FiG. 571. — Papillary Ovarian Cyst. 
a, a. Loculi containing papillar}^ growths. 



lage and a large amount of connective tissue. Dermoid growths may 
appear at any age. They have been found in children at birth and in 
women of ninety years. 

The contents of a dermoid are exceedingly irritating, and every pre- 
caution should be practised to prevent the peritoneal cavity from being 
soiled. I saw a patient in whom an attempted aspiration resulted in 
drawing out a wisp of hair; the patient at once developed peritonitis, 
which was fatal in spite of an early operation. 

342. Parovarian Cysts. The parovarium is situated in the lateral 
part of the mesosalpinx, and is the remains of the sexual part of the Wolf- 
fian body. It resembles in its arrangement a comb, the back of which 
is directed toward the tube, while the teeth, some twelve to fifteen in 
number, converge toward the ovary. They are lined with large cylindric 



782 GYNECOLOGY. 

epithelium and terminate in blind extremities. The tumors which 
originate from this structure are almost always cystic and subserous, and 
consequently have a double wall. The external peritoneal one is easily 
separable. The pedicle consists of the tube and of the median ovarian 
and the suspensory ligaments. Torsion of the pedicle, when long, can 
easily occur. There are two kinds of cysts which arise from the paro- 
varium, of which the most frequent are the small pedunculated, connected 
with Kobelt's tubules, which rarely become larger than a pea and are 
of no clinical significance. The more important are the sessile, which 
remain between the folds of the broad ligament and burrow into it as 
they enlarge. These cysts are usually small, though Kummel describes 
one that weighed forty- two pounds. In the large cysts the tube becomes 
elongated. The contents of the cyst are clear and limpid, with a specific 
gravity of loio and an alkaline reaction. 




Fig. 572. — Dermoid Ovarian Cyst. 

The parovarian and broad ligament cysts form about eleven per cent, 
of the abdominal tumors of pelvic origin, and both proliferating and 
dermoid growths have been found in this situation. 

These cysts are distinguished from the ovarian, first, by the ease with 
which the peritoneum can be stripped off; second, because the ovary 
generally is found attached to the side of the cyst; third, the cyst is uni- 
locular; fourth, the Fallopian tube is stretched over the cyst and never 
communicates with it; and, lastly, by the gradual thickening of the 
mesosalpinx. 

343. Solid Ovarian Tumors. The solid growths of the ovary com- 
prise five per cent, of the cases that present themselves for operation. 
These tumors are innocent and malignant, and may become cystic. 

Fibromyoma, the benign form, is a rare tumor, but is the most common 



OVARIAN TUMORS. 



783 



species of solid ovarian tumor. It closely resembles the uterine fibroma, 
and frequently is accompanied by ascites. Its growth is slow, and the 
mass retains the normal shape of the ovary. Adhesions are rare; indeed, 
owing to the peritoneal fluid, the mobility is increased. Occasionally, 
we have a growth — the fibroma — in which the minute structure consists 
of wavy bundles of closely packed fibrous tissue intermixed with small 
round cells. Williams describes one of these that weighed seven pounds 
seven ounces; Doran, one of seventeen pounds. The myomatous variety 





Fig. 573. — Filjronnoma of Ovary, 



Fig. 574. — Sarcoma of the Ovary. 



is more frequent, and occasionally undergoes calcareous degeneration, 
when it may be mistaken for an osseous tumor. 

An apparent hypertrophy, instead of atrophy, of the corpus luteum 
results in the formation of a growth, occasionally reaching the size of a 
walnut. Dr. Mary D. Jones pronounces this a gyroma, and believes it 
to be closely connected with the endothelium. It probably develops 
from the corpus luteum when in the cortex, and from the endothelium 
in the medulla. Leopold describes a peculiar form of ovarian fibroma 
containing alveolar spaces packed with epithelioid cells. They are pro- 
duced by dilatation of the lymphatic and capillary channels and the pro- 
liferation of their endothelium. 



784 GYNECOLOGY. 

Sarcoma of the Ovary. Sarcoma resembles the fibroid in form, size, 
and color, except that its surface is smoother. Its consistence is softer 
than the fibroid, though it contains much fibrous tissue, which renders 
the diagnosis at times difficult to determine. Sarcomata occur as round- 
cell and spindle-cell growths; when the latter predominate, the tumor is 
more solid and more strongly resembles the fibroma. The muscle-fibers 
are longer and the nuclei are more slender and rod-like. The round- 
cell structure is softer, often presenting macroscopically medullary prop- 
erties similar to those of medullary cancer, and under the microscope are 
found large layers and nests of round cells, united with irritation cells, 
and penetrated by numerous blood-vessels of every caliber. 

Spindle and round cells are frequently combined, while myxomatous 
transformation exists in both kinds. Cartilage and bone formation 
rarely occurs. 

Combinations of sarcoma with adenoma are observed in the walls 
of the larger cysts, sometimes with sarcomatous degeneration of the 
stroma. In places, large alveoli are separated by vascular connective 
tissue, which contains large cells undergoing fatty degeneration and 
resembling carcinoma. This condition Spiegelberg has called sarcoma 
carcinomatosum. 

Carcinoma of the ovary is a more frequent condition than sarcoma. 
The medullary variety is the most common, and may form a tumor as 
large as a man's head. The disease occurs primarily, but more frequently 
as a secondary manifestation. 

Endothelioma of the Ovary. Occasionally in the ovary a growth is 
found which originates from the endothelium of the lymph-spaces or 
blood-vessels of the organ. It has been previously classed by patholo- 
gists with both sarcoma and carcinoma, resembling the sarcoma from its 
frequent metastasis through the blood-vessels, a carcinoma in consist- 
ing of nests of cells with a fine stroma. The growth rarely attains a 
great size — not larger than an orange or fist — forms a solid tumor, and 
is a rather firm whitish growth. This same structure frequently is found 
complicating the glandular proliferating cysts, and gives evidence that 
many of these tumors, if carefully investigated, would show the presence 
of malignant conditions. 

Etiology. Little is known of the general cause of ovarian tumors. 
Three theories for their origin have been presented: i. The Cohnheim 
theory, which attributed their growth to the retention of embryonic pro- 
ducts; 2, the theory advanced by Mary A. Dixon- Jones, that they are 
always the result of previous attacks of inflammation, and the inflam- 
matory condition of the ovaries produces embryonal tissue from which 
the growth subsequently developed; and 3, the theory of parthenogene- 
sis, or the development of the nonfecundated ovum as the result of some 
irritation. The first and second theories are those which have the great- 
est number of advocates at the present day. According to the first, der- 
moids are derived from the infolding of the ectoderm in embryonic life, 
and these cells during subsequent irritation take an active growth and 
result in the formation of the various tissues found in a dermoid growth. 



OVARIAN TUMORS. 785 

It is claimed by the advocates of the theory of parthenogenesis that there 
are some structures found in the dermoid ovary which would require 
the infolding of all of the layers of the blastoderm in order to complete 
their development. The advocates of the first theory, however, direct 
attention to the fact that striated muscle is never found in the dermoid 
cysts. The character of irritation which sets in motion the development 
of these growths, whether mechanical or chemic, animate or inanimate, 
or whether it differs in the various kinds of tumors, is as yet unknown. 
The frequent occurrence in a cystadenoma of double-sided growth from 
the covering epithelium favors the belief in a chemic irritation which has 
proceeded by way of the uterus and tubes. The theory of the parasitic 
origin of tumors is as yet unproved, though the analogous course of tumor 
disease with infection has demonstrated that the development of vari- 
ous kinds of tumors in the different tissues of the body from metastatic 
deposits is of great interest. 

The susceptibility to the influence of tumor exciters varies greatly 
in different individuals; heredity, acquired disposition, age, trauma, scar 
formation, and inflammation are important factors. Of the influence of 
heredity little is known, though the occurrence of ovarian cysts in several 
women of one family is quite frequent. Age has no especial significance, 
as neoplasms occur in every period of life. Glandular cysts are more 
frequent between the thirtieth and fiftieth years. All varieties are less 
frequent in chfldhood and old age. Fetal tumors are rare, and generally 
consist of simple follicular cysts. These cysts increase in frequency 
as the chfld approaches puberty, probably being induced then by the 
congestive hyperemia. 

Ovarian growths are more frequent in the single than in the married. 
Scanzoni indicates chlorosis as a predisposing factor, and Fenwick, 
tuberculosis; but these are difficult to demonstrate. 

Natural Progress. Proliferating cysts in the advanced stages grow 
more rapidly than either the dermoid or solid tumors, unless the latter 
are malignant. About the early stage of ovarian tumors but little is 
known, as they are usually well advanced before they come under the 
observation of the physician. The growth is probably slow. In der- 
moids and in benign solid tumors the growth throughout is slow. A rapid 
increase in the size of a growth, noticeable from day to day, is a symptom 
due to hemorrhage. With the pelvic structures in a normal condition, 
the cystic ovary drops by its w^eight into Douglas' pouch, a little to one 
side of the median line. As it increases it advances in the direction of 
least resistance, which is upw^ard, and pushes the intestines before it, until 
it rises out of the pelvis and impinges against the abdominal wall, when it 
assumes a central position. The pedicle, at first anterior and inferior, 
is now directly beneath, and often becomes posterior. The tumor lies 
directly above the uterus, and, resting upon the brim of the pelvis, causes 
but little inconvenience. Occasionally, the tumor becomes impacted in 
the pelvis through irregularities in its growth or the formation of extensive 
adhesions. Sometimes the tumor pushes the broad ligament before it, or, 
when it develops in the hilum, it will spread out the ligament and become 
50 



786 GYNECOLOGY. 

an intraligamentary growth. Once the growth rests upon the pelvis, 
in its further advance it pushes the intestines upward and laterally. If 
undisturbed, the enlargement becomes great, the diaphragm is pushed 
upward, severe pressure symptoms follow, and the action of the heart 
and lungs is obstructed. The limbs appear as mere appendages to the 
enormous abdomen. The pressure affects the circulation, respiration, 
digestion, and the renal secretion. There are marked suffering, emacia- 
tion, and the characteristic facial expression known as fades ovariana. 
The presence of ovarian tumors does not interfere with ovulation and 
menstruation, even though both ovaries are involved, so long as any 
portion of the ovarian stroma remains undestroyed. Thorjiton reports 
a case of pregnancy with bilateral dermoid disease. In solid tumors 
amenorrhea is due to the total destruction of the Graafian follicles. 

Symptoms. In their early stages ovarian tumors rarely produce any 
symptoms. Movable tumors generally come first to observation when 
they rise out of the pelvis. An apple-sized tumor, though movable, oc- 
casionally will cause unpleasant symptoms, such as pain in the sacrum, 
which extends down the leg. 

Intraligamentary tumors or those prevented by adhesions from rising 
produce symptoms as soon as they fill the pelvis, especially by obstruc- 
tion to defecation and micturition. As the tumor increases, the sensations 
of pressure and unpleasantness are aggravated. Besides the effects given 
in the description of the progress, the skin becomes stretched, forms 
striae, and swelling of the navel and hernia occur. More rarely, from the 
pressure upon the great vessels, there are edema and varicosities in the 
legs, sexual apparatus, and skin of the abdomen. 

Albuminuria is present, and diminution of the urine from compres- 
sion of the renal veins is observed. This disappears with the removal 
of the pressure. Severe compression symptoms from the presence of 
very large tumors are rarely seen now. 

Uterine or vaginal prolapse sometimes complicates the condition, 
but more frequently ascites and fluid collections follow the rupture of a 
cyst. 

Menstruation usually is unaffected, and sometimes continues regular 
when subsequent microscopic investigation has failed to show any func- 
tionally capable structure. Menstruation disappears comparatively 
early in those cases in which the follicles perish from the development of 
sarcoma or carcinoma, and in the papillary cystadenoma, when bilateral. 
In contrast to fibroid tumor, the menstruation decreases, and a disposition 
to the menopause is betrayed, not from absent ovulation, but as the result 
of constitutional conditions. Amenorrhea may exist for several years 
and menstruation may return after the removal of an ovarian cyst. In 
intraligamentary growths, especially the papillary cystadenoma, severe 
menorrhagia occurs from pressure upon the uterine veins. 

Complications. Ascites occurs infrequently with cystic growths, unless 
from rupture, but frequently in the solid tumors. The cause is unknown. 
It may arise from pressure upon the venae cavae and large abdominal 
veins. Edema may involve one or both legs. Distention occurs in the 



OVARIAN TUMORS. 787 

pelvis of the kidney and in the ureter from pressure along the course of 
the latter. The most frequent complication is the formation of adhesions 
between the surface of the tumor and the omentum, the intestines, the 
uterus, the bladder, and the abdominal wall. These adhesions arise from 
inflammation, peritonitis, and sometimes painlessly. They possibly arise 
from the loss of surface epithelium of the cyst, through friction; fibrinous 
exudation results, and the formation of adhesions between adjacent 
surfaces. The adhesions become firm, dense, often thread-like, and be- 
tween the omentum and the growth may convey vessels of sufficient size 
to be an important factor in the blood-supply. Dermoids frequently are 
complicated by adhesions. When adhesions occur between the tumor and 
the bladder or the intestine, the cyst may open into either, and thus dis- 
charge its contents. A tuft of hair may project from a dermoid into the 
rectum or the bladder. Adhesions are of importance from the increased 
difiiculty in the removal of the growth. It is frequently exceedingly 
difiicult to distinguish the cyst-wall from the parietal peritoneum. 

Torsion of the Pedicle. A moderate twisting of the pedicle to 90 
degrees produces no symptoms; it is only when the torsion is sufficient 
to influence the circulation, or above 180 degrees, that disturbance is 
occasioned. A slight twisting always occurs with the elevation of the 
cyst from the pelvis. The right-sided tumor turns to the left, and the 
left-sided to the right. The cause of the torsion is unknown. Kustner 
ascribed it to peristalsis and the changes from the distention of the rectum; 
Cario, to sudden belly pressure; Mickwitz, to contraction of the trans- 
versalis muscle. The influence of pregnancy and changes of position in 
a relaxed abdomen which contains a tumor with a long pedicle are 
factors. This torsion may readily arise from manipulation to determine 
the diagnosis. I saw it occur in a young girl who had been thrown upon 
the floor by her companion, who sat upon her abdomen. The torsion 
may occur with very small tumors which are still within the pelvis, in 
which it most probably arises from the varying distention of the bladder 
and rectum. The twist may involve but one or two turns of the pedicle, 
though as many as six twists have been observed. The tube usually 
shares in the twisting, and torsion of the uterus infrequently has oc- 
curred. Torsion of the pedicle may take place in any variety of tumor, 
though from its greater frequency it is found most often in the cystaden- 
oma. Dermoids and parovarian growths also show a marked tendency 
to undergo pedicle-torsion. The tendency to torsion of the pedicle is 
favored by the existence of a long, membranous pedicle, a spheric form 
of the tumor, and a smooth surface. The twisting is still further favored 
by pregnancy, labor, and child-bed, through the changing relations of the 
organs in the abdominal cavity. 

The results of the torsion are dependent upon the rapidity with 
which it has occurred. The torsion causes obstruction of the vessels, 
in which the thin-walled veins suffer before the more resistant arteries. 
There necessarily results an increased engorgement of the blood in the 
tumor. Solid tumors are completely penetrated by blood, and cystic 
growths undergo hemorrhagic infiltration of the walls as well as of the 



788 



GYNECOLOGY. 



contents. The surface presents a black, blue, or dirty brown color, the 
cyst rapidly increases in volume, and as a result breaks down easily. A 
fatal result may occur from hemorrhage into the abdominal cavity. More 
frequently hemorrhage is arrested, but the nutrition of the tumor suffers. 
The covering epithelium is lost, and extensive adhesions occur between the 
surface of the tumor and the surrounding structures, as the omentum, 
intestines, and parietal peritoneum. 




Fig. 575. — Torsion of the Pedicle. 

These adhesions are, at first very loose, then become organized, and 
the growth thereby obtains a new source of nutrition, by which it maintains 
its size or proceeds to new growth. Further twisting leads to obstruc- 
tion of the arteries, which is followed by necrosis of the growth. Necrosis 
is followed by shrinking of the tumor from the absorption of its fatty 
constituents, though it rarely disappears. It may become calcified. 
Peritonitis, with the formation of extensive ascites, almost always results, 
The peritonitis arises independent of micro-organisms, and is due to the 



OVARIAN TUMORS. 789 

irritation from the presence of a foreign body or to the chemic products 
of the tumor. An infection may occur through the tube or from kinking 
of the intestine. Sometimes suppuration of the tumor and pyemia 
ensue. A slight torsion may bring edema instead of hemorrhage, and 
ascites instead of peritonitis. The pedicle may be found attenuated, or 
its thickness may be doubled. The dermoid growths are sometimes 
found free in the abdominal cavity or in pedicle-like adhesion with other 
structures. A dermoid under my observation was held in front of the 
uterus by adhesions above to the omentum, and below to the peritoneum; 
the tube and upper part of the broad ligament upon the left side had en- 
tirely disappeared. The separation evidently was old, for the wall of the 
growth had undergone calcareous degeneration. Ileus has resulted from 
the adhesion of a loop of intestine to the tumor or to its pedicle. 

Symptoms. Frequently there are no symptoms of torsion. Such cases 
are usually recent or the torsion has been slight. It may be suspected 
when the patient is taken with severe pain in the belly, associated with 
meteorism, and sensibility to pressure, acceleration of the pulse, sometimes 
also singultus, vomiting, and fever. In torsion of high degree indications 
of intra-abdominal bleeding appear frequently with marked collapse. In 
the chronic condition the pain and unfavorable symptoms are more grad- 
ual, though many patients are bedridden fand show a distinct loss of 
strength, occasioned by the absorption of the altered constituents of the 
tumors producing a condition resembling cachexia. 

Inflammation and Suppiration of the Cyst. . Cysts may undergo in- 
flammatory and suppurative changes, though much less frequently thart 
formerly, as puncture of the cyst is not so often practised. In some 
tumors the contents of which resemble pus,' the microscope demonstrates 
that the material consists of epithelium and cell detritus, but not of 
leukocytes. The inflammation is communicated mostly by the tube 
and intestine; the latter especially when adhesions have taken place 
between the intestine and the sac. Opportunities for infection are 
increased by parturition and the puerperium, as a result of the pos- 
sible trauma occasioned during labor. Dermoid tumors are inclined to 
suppuration, formerly supposed to be due to the peculiar pus-exciting 
character of their contents, but more probably the result of injury which 
the tumor has undergone during its long retention within the body. 
We have already seen that the dermoid was prone to torsion of its pedicle, 
and its contents are an excellent culture-medium for the propagation 
of bacteria. 

Symptoms. The occurrence of inflammation and suppuration is 
characterized by fever and typhoid phenomena, which vary in intensity 
according to the nature of the infection. The patient does not experience 
much pain unless peritonitis is associated. The pulse becomes rapid 
and emaciation is progressive. Adhesipns to the suppurating tumor 
occur, and the pus makes its exit, as in ovarian abscess, into the bladder, 
the rectum, or the vagina. It is but rarely that the pus is completely 
evacuated and spontaneous recovery results. Death usually follows 
from pyemia. A rupture into the peritoneal cavity is followed quickly 



790 GYNECOLOGY. 

by fatal peritonitis. The evacuation of such a tumor through the blad- 
der produces the greatest distress, as hair, teeth, and pieces of bone are 
discharged, sloughs become impacted in the urethra and induce cystitis, 
and there are retention of urine and marked vesical tenesmus. Frag- 
ments which remain in the bladder are coated over with urine salts, and 
become the nuclei of calculi. 

Rupture of cystic tumors may occur suddenly as the result of a fall 
or blow, or gradually may result from changes in the cyst-wall. It 
occasionally follows from internal pressure caused by the growth of the 
tumor. The latter accident produces no symptoms, and it is only ex- 
ceptionally that hemorrhage complicates spontaneous rupture. In 





Fig. 576. — Dermoid Which Had Lost Its Original Relations and Was Nourished by Adhesions 

from the Omentum. 

papillary growths the pressure of the vegetations causes thinning of the 
cyst wall, and, finally, rupture; or the growths project through the wall 
of the cyst, to extend over its external surface. Rupture of a cyst may 
occur into the surrounding viscera, but more frequently takes place into 
the peritoneal cavity. In very thin-walled cysts this rupture occurs 
easily. Manipulation to determine the diagnosis, changing the position 
in bed, the act of coition, or vomiting, may produce it. It frequently 
occurs without assignable cause. The influence of the accident will 
naturally depend upon the character of the cyst-contents. Often, in 
the unilocular cysts, rupture into the peritoneal cavity is attended with 
no untoward symptoms, beyond an excessive flow of pale urine. The 
patient will often pass several gallons of urine in twenty-four hours, 
and the abdomen, which was large, will become flattened, flabby, and 
readily permit the residual sac to be recognized by palpation. In single 
and parovarian cysts recovery occasionally may follow the rupture. 



OVARIAN TUMORS. 79 1 

Generally, the opening is closed by adhesions, and the fluid reaccumulates. 
In some cases the accident is followed by high temperature, rapid pulse, 
vomiting, pressure at stool, and diarrhea, which indicate the absorption 
of the contents and the development of a form of auto-intoxication. In 
multilocular and dermoid growths the rupture into the peritoneal cavity 
ordinarily is followed by infection, a rapidly developing peritonitis, and, 
finally, death. Such a termination is probable not only in dermoid, but 
also in those cysts containing colloid material and pus. In the papillary 
cysts rupture results in the infection of the peritoneum, the formation 
of ascites, and the development of vegetations over the entire cavity. 
Sometimes an artery is torn in the rupture, and marked hemorrhage, 
with profound anemia, follows. Profound collapse has been noted. 

The occurrence of rupture is recognized by the disappearance of, 
or diminution in the size of, the tumor, the recognition of free fluid in 
the peritoneal cavity, peritonitis, collapse, diarrhea, and diuresis. The 
accident may be mistaken for torsion. Rupture into the intestine is 
evident from the character of the discharges and should be suspected 
when a profuse watery discharge escapes from the bowel. External 
rupture usually is recognized easily. When the discharge is pus or icho- 
rous material alone, it is often difiicult to determine whether it is from 
a cyst or an abscess in the walls. 

Complication of Ovarian Tumor with Pregnancy. The existence of 
ovarian growths does not preclude the occurrence of pregnancy, though 
their coexistence is comparatively rare. It is more frequent in the one- 
sided, though it occurs sufficiently often in double-sided, disease to dem- 
onstrate its possibility as long as any functionating portion of ovary re- 
mains. The complication may occur with any variety of ovarian tumor, 
though it is more likely to complicate the slow-growing forms — the der- 
moid and the pseudomucin — than the others. Numerous cases are re- 
corded in which the patient carrying an ovarian tumor has successfully 
run the gauntlet of several pregnancies. The existence of such a tumor, 
however, does increase the distressing symptoms and the danger of preg- 
nancy. There is not the same tendency to rapid growth of the cyst during 
pregnancy as exists when a fibroid growth is complicated by the same 
condition. The assertion that the occurrence of pregnancy favors malig- 
nant degeneration in the cyst is unproved. The occurrence of carcinoma 
in a cyst during pregnancy is no proof that it was not previously there, 
nor that it would not have occurred had pregnancy never existed. The 
changing relations of pregnancy, labor, and the puerperium undoubtedly 
favor the occurrence of torsion of the pedicle; and the delivery of the 
fetus, whether naturally or by the use of instruments, frequently crushes 
or bruises the cyst so that it ruptures or undergoes inflammation and sup- 
puration. While the varying relations of pregnancy, labor, and the puer- 
perium exert an injurious influence upon the progress of the tumor, 
it can, on the contrary, greatly disturb these processes. The diminished 
space in the abdomen affords less room for the normal development and 
increases the danger of abortion and premature delivery. Abortion 
frequently has been reported as a result of the retroflexion of the uterus 



792 GYNECOLOGY. 

produced by the tumor. In labor a large tumor may interfere materially 
with the normal forces of delivery by decreasing the activity of the con- 
tractions and by altering the situation of the uterus. More worthy of 
consideration is the situation of a tumor of small size in the pelvis, below 
the uterus, where it acts as an obstruction to the progress of the child's 
head. If the tumor is not flattened or pulled out of the pelvis, the head 
of the child cannot enter, and, unless otherwise alleviated, labor may 
terminate in rupture of the uterus, tearing of the vagina, or bursting of 






Fig. 577. — An Ovarian Cyst beneath a Pregnant Uterus. 

the cyst. Such complications necessarily are attended with danger. 
The puerperium may be complicated by gangrenous processes in the 
tumor and its pedicle, following the injury of labor. 

The coexistence with pregnancy of ovarian tumor, when large, causes 
increased difhculty in respiration, through pressure upon the diaphragm, 
and may cause danger to life by the pressure and the tendency to albu- 
minuria and edema. The tendency to torsion of the pedicle, to rupture 
of the sac, and to subsequent inflammation naturally clouds the prognosis. 

When the cyst is situated in advance of the uterus, an effort should be 
made to push it up, and, upon failure, we may be left to the choice be- 



0VARL4N TUMORS. 793 

tween delivery of the growth through a vaginal incision or its puncture 
through that canal and its removal after delivery. In the early months 
of the pregnancy operative interference for the removal of the tumor has 
little influence upon the progress of the pregnancy, and should be con- 
sidered whenever the size and situation of the growth threaten the suc- 
cessful termination of the pregnancy. 

Degenerative Changes in the Cyst-walls. The cyst-walls may undergo 
the following degenerative processes : 

First, calcification, which occurs most frequently in the inner layer of 
the main cyst-wall in the form of small granules or plates of lime, or the 
formation of psammous bodies similar to those seen in the papillary 
cysts. Calcification is increased with the impairment of nutrition follow- 
ing gradual torsion. In a case of dermoid which came under my observa- 
tion the deposit was so extensive that the tumor resembled a calcareous 
fibroid. 

Second, /a//)' degeneration occurs in the papillary cells and in the con- 
nective tissue of walls of the cyst. This process is enhanced by impair- 
ment of nutrition. The change in the septa of cysts occurs from the 
pressure of their contents, and ends in their partial or complete destruction. 
The presence of a large amount of fat in the walls is an evidence of slow 
growth. 

Third, atheromatous changes, which generally occur in the inner 
layer of the wall. 

Fourth, changes due to infarctions, which are indicated by whitish, 
opaque bodies found in the septa and surrounded by a red zone. 

Diagnosis. Inspection, palpation, percussion and auscultation in 
the diagnosis of ovarian tumors are used to determine the physical signs. 
(The method of procedure and the information derived therefrom has been 
given.) (§44-48.) The readiness with which the diagnosis will be de- 
termined depends upon the size, situation, relation and complications of 
the tumor. 

The questions under consideration are: i, Is the abdominal enlarge- 
ment under observation a tumor ? 2, The existence of a tumor recognized, 
is it an ovarian growth? 3, An ovarian tumor admitted, what are its re- 
lations to the surrounding parts ? Has it a pedicle ? Are there adhesions ? 
4, WTiat variety of ovarian tumor is it ? 

The first question, Is the distention of the abdomen an intra-abdominal 
tumor? may seem unnecessary, but the frequency with which various 
enlargements of the abdomen are mistaken for growths, and the occa- 
sional difficulty in arriving at a certain determination fully justify its 
careful consideration. For convenience of study we divide the ovarian 
growths into small, or those situated within the pelvis, and large, when 
they are resting upon the pelvic brim. 

The extra-abdominal enlargements, other than tumors, with which 
an ovarian tumor may be confused are obesity, desmoid tumor of the 
abdominal walls, ventral hernia, tympanites, fecal accumulation, dis- 
tended bladder, ascites, and localized peritoneal efl'usion. 

Obesity. A large, pendulous abdomen, from the accumulation of fat 



794 



GYNECOLOGY. 



within its walls or in the omentum, is sometimes mistaken for an ovarian 
tumor. The history of its development and the distribution of adipose 
tissue to other parts of the body, contrasted with the general emaciation 
of an ovarian cyst, should assist in determining the diagnosis. The thick- 
ness of the fat accumulation can be estimated pretty accurately by 
grasping a fold of the skin and subcutaneous tissue between the thumb 
and fingers. 

Desmoid tumor of the abdominal walls is infrequent, develops in 
the muscle-wall, and partakes of the nature of a fibroid. Generally, 



w 




Fig. 578. — Desmoid Tumor of Abdominal Wall. 

from its weight, it forms a dependent tumor, which sometimes hangs 
over the knees. In rare instances it grows inward, pushing the peri- 
toneum before it as a part of its covering and fills the abdominal cavity. 
It generally moves with the abdominal wall, and is superficial and very 
hard. Its situation in the wall, covered by the skin and superficial 
fascia, and the determination by vaginal or rectal examination of the 
absence of any connection with the pelvic viscera, determine its character. 
Ventral Hernia. Twice in diastasis of the recti muscles with a large 
protrusion of the viscera have I been called a long distance to operate 



OVARIAN TUMORS. 795 

for supposed ovarian cyst. Palpation of the intestinal coils, resonance 
upon percussion, and observation of the peristalsis, readily seen through 
the thin covering of skin and peritoneum, should have excluded the 
diagnosis of a cyst. 

Tympanites. A localized tympanites or phantom tumor, a condition 
similar to pesudocyesis, is sometimes mistaken for an ovarian cyst. 
The loud volume of resonance obtained by percussion should be considered 
as contra-indicating the probability of the existence of a cyst. It is true 
that in rare instances a communication of a cyst with the bowel will permit 
it to become resonant. A similar condition will arise from decomposition 
of cyst-contents, by which gas forms in the cavity. Even in these cases 
a sense of fluctuation may be secured, which is absent in the phantom 
tumor. The latter will entirely disappear while the patient is under an 
anesthetic, to return as soon as the patient recovers. 

An accumulation of feces is sometimes called a fecal tumor. It forms 
in the colon, and when in the transverse portion of the gut, may descend 
and lie directly over the pelvis. These accumulations are occasionally 
quite extensive, but are recognizable by their length, by the peculiar sensa- 
tion under palpation, and by the possibility of leaving an imprint upon 
pressure, but most of all by the fact that they disappear under the ad- 
ministration of purgatives and enemas. 

A distended bladder forms a tumor in the lower part of the abdomen 
which fluctuates and very readily may be mistaken for an ovarian cyst. 
This suspicion apparently is confirmed by the information that the patient 
is constantly passihg urine. The fixed position, and the bulging of the 
anterior wall of the vagina, should be sufficient to indicate the use of a 
catheter, when the tumor will disappear. It should be the invariable 
rule to empty the bowel and bladder preliminary to the examination of 
an abdominal tumor. 

In pregnancy, fibroid tumor, or even a simple ovarian tumor impacted 
in the pelvis the urethra may be so distorted and compressed as to render 
necessary the use of a soft male catheter. 

Ascites. In uncomplicated ovarian cysts the differential diagnosis 
from ascites is not difficult to make The cysts have, in common with 
ascites, enlargement of the abdomen, fluctuation, and the symptoms 
arising from pressure against the diaphragm. Frequently both conditions 
will be characterized by progressive loss of strength and flesh and by 
more or less edema of other parts of the body, but there is a marked 
difference in the manifestation of these symptoms when we come to analyze 
them. The enlarged abdomen in ascites is more or less flattened and its 
widest diameter is transverse, while the ovarian cyst is most prominent 
in the vertical diameter and is narrow from side to side. Fluctuation is 
very distinct over the abdomen in ascites and in unilocular cysts, but the 
wave of fluctuation will be found to extend nearer to the vertebrae in the 
former. In the well-filled cyst the projection of the vertebrae prevents 
the approach of the fluid to the lumbar regions. In multilocular cysts 
the wave of fluctuation is more broken, and frequently is recognized 
only as a sensation of elasticity. The loss of strength is often more 



796 



GYNECOLOGY. 



marked in ascites, while the appearance of emaciation is greater in the 
cyst. In renal and cardiac dropsy there is much greater disposition to 
anasarca. In a very advanced and large ovarian tumor the pressure 
may induce considerable dropsy of the extremities, but the abdominal 
distention is in much greater proportion. 

On palpation the ovarian tumor presents greater resistance and fre- 



HEPATIC 
DULNES3 





NTESTINAL 



jZ!;0/^'f_±_ RESONANCE-- ^^^^ 



fl 



ANKSj 



Fig. 579. — Relative Zones of Dullness and Resonance in Ascites. 

quently can be outlined and its surfaces distinctly determined. The 
abdominal surface can be moved over the tumor and the upper margin 
is recognized easily. The existence of adhesions or the presence of a large 
quantity of fluid may obscure the conditions. Percussion affords the 
most valuable information. In ascites there is a distinct zone of resonance 
over the center of the abdomen, or the point of greatest prominence, 



OVARIAN TUMORS. 



797 



while the more dependent portions are dull. The zone of resonance 
changes with the position of the patient. In ovarian cyst, on the contrary, 
there is dullness upon percussion over the whole surface of the tumor, 
and resonance only after we have passed beyond its limits, which is un- 
changed by position. As the tumor, in its growth, presses the intestines 
upward and to the opposite side before it, the resonance generally will 




Fig. 580. — Relative Zones of Dulla.-o^ ani Resonance in Ovarian Cyst. 

be discovered above, and on the side opposite to that upon which the tumor 
has originated. Occasionally, in a distended colon, resonance may be 
secured over it in ascites. When the abdomen is greatly distended, or 
when inflammatory conditions bind down the intestines, resonance will 
be absent upon superficial percussion, but may be determined easily when 
more pressure is used. The pressure displaces the intervening layer of 



798 GYNECOLOGY. 

fluid and permits resonance to be obtained. In tubercular peritonitis 
and in hepatic dropsy, when the mesentery has undergone contraction and 
the peritoneum is very much thickened, the diagnosis can be so obscure as 
to require an abdominal incision to determine it. 

Ascites may complicate an ovarian cyst, when, by displacement of a 
layer of fluid, the hand will come in contact with the cyst. The amount of 
resistance will afford information as to whether the tumor is solid or cystic. 
The complication of ascites may be regarded as an evidence of malignancy 
or of some degenerative process. The greater the amount of ascites, 
the more probable the malignancy. I have, however, seen very large 
ascitic accumulations from necrosis of a cyst after torsion of its pedicle. 
The uterus is freely movable, in ascites, while in ovarian cyst it is but 
slightly movable, and displaced either downward and backward or upward 
and forward. In ascites arising from ruptured papillary cyst a dense, 
thickened mass is recognized upon each side of the uterus, which should 
cause a suspicion as to the character and origin of the disorder. 

Localized peritoneal effusion within the abdominal cavity offer great 
difficulties in determining the diagnosis. Such accumulations are gener- 
ally the result of tubercular disease, and the history of the development of 
the disorder, the general condition of the patient, and careful investigation 
of the abdomen will afford an intimation as to its character. I mistook a 
collection within the lesser peritoneal cavity for an ovarian cyst. The 
abdomen presented the characteristic appearance of a large ovarian cyst. 
A vaginal examination would have revealed the uterus and ovaries below 
a collection which did not dip into the pelvis, but, unfortunately, no such 
investigation was made. The diagnosis of ovarian growth was accepted 
upon the external appearance. Upon abdominal incision the general peri- 
toneal cavity was free from fluid. An apparent cyst upon which the in- 
testines were spread projected into the incision, from which over three 
gallons of straw-colored fluid were withdrawn, and investigation demon- 
strated the character of the cavity. 

Second, Is the tumor under observation an ovarian tumor? The phys- 
ical signs vary with the size and situation of the tumor. In the early stage 
the tumor is entirely within the pelvis, and its position varies. When 
it reaches the size of a hen's egg, the tumor falls into the pelvis, where it 
remains until it becomes too large to be accommodated longer in that 
situation. Its relation to the corresponding side of the uterus permits 
its character to be determined by conjoined manipulation. When the 
growth has been complicated by peritonitis, the diagnosis^ay be difficult. 
Small tumors usually feel firm because they are not sufficiently large to 
aff'ord fluctuation, or even elasticity. The latter is of importance, and is 
generally absent in proliferating cystomata, in dermoids, and even in 
small single cysts. When we are unable to separate the tumor from the 
uterus, and consequently to determine the existence of a pedicle, the latter 
can be ascertained by Hegar's method. This, whfle the patient lies upon 
her back, consists in seizing the uterus with a vulsellum and dragging it 
well down, while two fingers in the recum follow its borders to determine 
its relation to the growth, or the hand over the abdomen can depress the 



OVARLA.N TUMORS. 



799 



fundus and thus recognize its relation. When a tumor is not large, it 
usually can be outlined by a hand over the abdomen and a finger in the 
rectum. The greatest difficulty is experienced when the tumor is com- 
plicated by inflammatory conditions, is fixed, and often incarcerated. 
Tumors which have originated in the broad ligament, and lie in close 
relation to the uterus, are usually less spheric and circumscribed, and less 
movable from their first inception. Fibroid tumors of the uterus and 
inflammatory enlargements of the tubes are likely to be confused with 
small ovarian cysts. These are pyosalpinx, hydrosalpinx, and hemato- 
salpinx. The acute history, marked tenderness, evidence of inflamma- 
tory exudation, thickening, and matting together of the pelvic tissues, 




Fig. 581. — Hegar's Method of Determining Relation of Tumor to the Uterus. 



associated with marked pain, should distinguish the pyosalpinx. In hy- 
drosalpinx the tumor may be movable, and may give a sensation of elas- 
ticity or fluctuation, but is oblong or gourd-like, rather than spheric. It 
is frequently closely adherent to the uterus, and affords a history of pre- 
vious inflammation. A hematosalpinx is at first soft, then becomes hard 
from the coagulation of the blood. They are usually situated to one side 
of the pelvis and posterior to the uterus. Fibroid growths are firmer and 
are closely attached to the uterus. 

Large or Abdominal Growths. A large ovarian cyst distends the ab- 
domen, particularly at its lower part, rises abruptly from the pubes, 
is sharply defined and generally symmetrically developed. Its outline, 
extent, and size are readily determined by palpation. In a large single 
cyst the surface will be smooth and regular, while in the multilocular 



8oO GYNECOLOGY. 

cysts projections and irregularities are often found. If it is made up of a 
large number of small cysts, it will be more resistant, although it will 
still present a sensation of elasticity. These growths are confounded 
with pregnancy, hydramnios, extra-uterine gestation, uterine myomata, 
retroperitoneal growths, and tumors of the various viscera of the abdom- 
inal cavity. 

Pregnancy. Enlargement of the abdomen is more rapid than in 
ovarian tumor. It is generally associated with suppression of the menses 
and the presence of such sympathetic nervous phenomena as nausea, vom- 
iting, disturbed appetite, and, in the more advanced stage, a florid, healthy 
appearance of the patient. Suppression of the menses is not a constant 
symptom of pregnancy, for there are some women who continue to men- 
struate during the entire pregnancy, nor is amenorrhea always absent in 
ovarian growths. Error is more likely to occur in the unmarried, during 
the early stage of pregnancy. The physician should refrain from making 
a diagnosis until he has had an opportunity to make a careful examina- 
tion, and then should hesitate to express an opinion when there is the 
least reason for doubt. An examination a few weeks later will dispel the 
uncertainty. There is an absence of fluctuation in pregnancy; but it 
is also absent in cysts with thick, viscid contents, or in the areolar and 
glandular varieties, which are made up of a large number of small cysts. 
As pregnancy advances, the fetal movements, heart-sounds, and parts of 
the fetus are recognizable. The heart-sounds are pathognomonic of 
pregnancy, but are not always heard, owing to the position of the fetus, 
the large quantity of fluid, or to fetal death. The conjoined manipula- 
tion will afford information as to the relation of the enlargement to the 
uterus. Gestation in one horn of a bicornate uterus can make the diag- 
nosis difhcult, but a careful bimanual exploration will demonstrate the 
association of the enlargement with the uterus, and the small undeveloped 
cornu in association with the enlargement. Under no circumstances 
should the size of the uterus be determined with a probe when there is the 
least suspicion of pregnancy. 

Hydramnios is a pathologic form of pregnancy in which there is a 
more or less large collection of amniotic fluid in the uterine cavity. Cases 
in which the collection exceeds two quarts have been mistaken for ova- 
rian cysts. In large collections the abdominal cavity becomes greatly 
distended; its surface is smooth, white, and glistening, and fluctuation 
is very distinct. The patient suffers all the discomfort characteristic of 
a large cyst. The history will prove of value in determining the diagno- 
sis. Hydramnios generally occurs suddenly, and makes its appearance 
about the sixth or seventh month of a pregnancy which has previously 
run a normal course. Such symptoms could aris.e only from an ovarian 
cyst which had undergone some marked change in its nutrition, but this 
diagnosis would be excluded by the previous indications of pregnancy. 
The physical examination of such a patient will disclose an enlarged 
uterus, the cervix of which frequently is obliterated, with the os open, 
and covered with a dense membrane, through which, by manipulation, 
we are often able to distinguish parts of the fetus or obtain ballottement. 



OVARIAN TUMORS. 8oi 

Rupture of the membrane is followed by the discharge of a large quantity 
of water and evacuation of the uterine contents. The existence of an 
ovarian cyst does not preclude the occurrence of pregnancy, and the 
presence of the latter, by the increased flow of blood to the pelvis, may 
facilitate the growth of the cyst. The rapidity of the growth may be so 
great as to require early interference in order to save the life of the patient. 
Careful examination usually will disclose an enlarged uterus either in 
front of or behind the cyst. 

An ectopic gestation which has attained a size sufficient to permit it to 
be confused with an ovarian cyst will have presented the symptoms of 
early pregnancy, possibly indications of rupture of the sac, and internal 
hemorrhage. Later, the tumor may be found to one side of or behind the 
uterus, and so closely adherent to it as to render the differentiation from it 
exceedingly difficult. In advanced stages the fetal movements and the 
heart-sounds may be heard. Vaginal palpation will disclose the fetal 
parts covered with a thin wall. After the death of the fetus other changes 
occur which render the diagnosis still more difficult. The fetus shrinks, 
becomes macerated, and the decomposition produces an accumulation of 
gas, which, , with the distinct fluctuation, makes the condition doubly 
obscure. A careful analysis of the subjective symptoms, associated with a 
thorough examination, will generally permit its recognition. 

Uterine Myomata. Generally the slow growth, the resistance of the 
tumor, the usual presence of multiple growths, their irregular contour, 
and their demonstrable relation to the uterus, should afford confirmation 
of the diagnosis. , A tumor which has but recently come under the observa- 
tion of the patient, and has, through degenerative or obstructive processes, 
taken upon itself rapid growth, may afford considerable difficulty in the 
determination of its true character. The difficulty becomes greater in 
edematous fibroids and in fibrocystic tumors. It would seem that the 
demonstration of the continuation of the mass with the cervix would be 
s'ufficient to demonstrate the uterine origin. Double ovarian cysts, 
particularly when the pedicle is short or absent, may so drag upon the 
fundus uteri as to make it apparent that the growths are a part of the 
uterus. The relation of the uterus to the tumor is best determined by 
grasping the cervix with a vulsellum, which is held by an assistant; a 
second assistant draws up the tumor through the abdominal walls, while 
the principal, with one or two fingers in the rectum, and the hand over the 
abdomen, seeks the pedicle and ascertains its relation to the uterus. This 
procedure, even in double growths, will permit the fundus to be recognized 
and the nonuterine character of the growths to become known. In the 
early history of abdominal work the abdomen frequently was opened 
for an ovariotomy and a uterine fibroid was discovered. Indeed, the earlier 
removals of the uterus were cases of mistaken diagnosis. Uterine myo- 
mata may complicate the presence of an ovarian cyst, and the consequent 
distention of the abdomen from the presence of two large tumors may 
render earlier interference desirable. The ovarian cyst may be situated in 
front of the myomatous uterus, and the growth may be unsuspected until 
discovered during the progress of an operation. 



8o4 



GYNECOLOGY. 



tive indication, of papillary growths, as the conjunction of such symptoms 
is found in all tumors. Superficial papillomata feel firm, nodular, and are 
often diffusely extended in the pelvis. In a rapidly developing ascites, in 
which renal, cardiac, and hepatic causes can be excluded, the presence of 
bilateral resistance in the pelvis should awaken a suspicion of ruptured 
papillary ovarian cyst. A pronounced solid consistency of the growth is 
common to ovarian fibromata, sarcomata, endotheliomata, carcinomata, 
and teratomata. 

Ascitic conditions may complicate all these tumor formations. Ascites 
when present increases the difficulty of palpation and renders the diagnosis 
more uncertain. The fibromata and the fibrosarcomata are more or less 
nodular, of quite firm consistence, and are more frequently situated upon 
one side. Sarcomata and endotheliomata are generally softer. The solid 
carcinomata are mostly bilateral, quite nodular, and offer a sensation of 
toughness. There are no positive indications that a tumor is benign or 
malignant, as a cystadenoma may contain masses of cancer material. 
Ascites is generally regarded as an indication of malignancy, but it occurs 
in pseudomucin cysts, papillary growths, and with the fibromata. Hard 
consistency and an irregular surface are also reasons for suspicion, but are 
not positive indications. Early adhesion of the tumor, which prevents the 
vaginal wall from being moved over it, is an indication of malignancy, 
when abscess formation can be excluded. 

The age of the patient is of little significance, as the age of the climac- 
teric is inclined to the formation of cancer, and all varieties of ovarian 
tumor may occur at any period of life. Proper metastases, as distin- 
guished from peritoneal implantation, are of significance, but it is not 
always easy to demonstrate these metastases, as they do not always cause 
symptoms, or are not perceptible because of the abundant ascites. In 
other cases metastases will have been discovered in the vagina, the para- 
metrium, and the rectal and peripheral lymph-glands before operation, 
fixing the diagnosis of malignancy without question. Pronounced 
cachexia and marasmus may be produced by certain complications, such 
as rupture, torsion, and inflammation; also in tumors of enormous size. 
Rapid growth, especially in children, speaks for malignancy. Olshausen 
directs attention to the early edema of one leg as a symptom of cancer. 

Exploratory Puncture. In obscure and complicated cases it was 
formerly the rule, before resort to operation, to draw off a portion of the 
cyst-contents for chemic and microscopic examination. The fluid may 
have such pronounced physical properties as to reveal the true character 
of the growth. The thick colloid material from proliferating cysts can be 
mistaken for nothing else. If the fluid is serous, the possibilities of origin 
are numerous. It may have been furnished by a parovarian cyst, a serous 
ovarian tumor, a cystadenoma, ascites, hydronephrosis, and echinococcus 
sacs. In uncomplicated cases the fluid may possess such chemic properties 
as will aid in the differentiation, but frequently these properties are lost 
through complications, such as serous transudation and an admixture of 
blood. The fluid from a proliferating cyst is thick and coUoid, with a 
specific gravity of from 1015 to 1030, and contains paralbumin and cylindric 



OVARIAN TUMORS. ' 805 

cells. In the papillary cysts there is an absence of paralbumin, while 
white blood-corpuscles are revealed by the microscope. The fluid from 
the Graafian follicles does not differ from that of the parovarian cysts. 
Ascitic fluid is thin and of a light yellow or greenish color, from which 
albumin is coagulated upon boiling, but no cylindric epithelium is found, 
and the specific gravity is from 1008 to 1015. In the cystic fibroma the 
fluid is of a lemon-yellow color, has a specific gravity of 1020, coagulates 
rapidly without heat, and contains no cylindric epithelium. The fluid 
from echinococcus cysts presents booklets, has a specific gravity of from 
1008 to 1 010, and does not contain albumin. In hydronephrosis the fluid 
is thin, with a specific gravity of from 1005 to 1018; its color varies, and 
it contains urea, leucin, tyrosin, and kreatinin. Puncture of a cyst is 
always attended with danger, and when performed in doubtful cases, for 
diagnostic purposes only, — as in the echinococcus cysts, renal tumors, 
abscesses, and dermoids, — is attended with the most serious consequences: 
the intestines and bladder frequently have been punctured; fluid may 
escape into the peritoneal cavity and cause peritonitis; or air may enter the 
sac and result in inflammation and suppuration; a large vessel in the sac- 
wall has been injured, and a severe and dangerous hemorrhage has re- 
sulted. Neither chemic nor microscopic examination of the cyst-contents 
affords positive information, and the inferences thus secured do not com- 
pensate for the increased danger the patient undergoes. 

Exploratory Incision. In cases in which we find it impossible to arrive 
at a positive diagnosis, as in tubercular peritonitis, in malignant disease of 
the ovary, tube, or omentum, or in papillary cysts, a button-hole incision, 
sufficiently large to permit the introduction of the finger, will be a far 
safer procedure than puncture, will afford an opportunity to determine 
the condition by touch, and will permit subsequent drainage. It should be 
done under all antiseptic precautions, and every preparation should be 
made to complete the operation if the conditions will permit. While this 
procedure is unattended with great danger, its indiscriminate practice is 
unjustifiable. It should not be utilized to secure information that may 
as well be secured by the bimanual examination. WTien the latter pro- 
cedure has demonstrated an inoperable malignant condition, for instance, 
the incision should not be made merely for confirmation of the decision. 

Treatment. That an ovarian cyst is not amenable to medicinal treat- 
ment is evident when we consider that the fluid is contained within a closed 
sac, which has its own secreting surface. The administration of remedies, 
and the application of counterirritants to increase secretion and elimina- 
tion, must be without avail. Electrolysis has had its advocates, but when 
we consider the character of these growths, and the danger from infection 
many of them must present, the folly of such treatment is evident. Surgical 
treatment should consist in extirpation. Puncture is but a palliative 
procedure at best, for the removal of the fluid is quickly followed by its 
re-formation, and it requires more and more frequent withdrawal, which 
proves a severe drain, through the great loss of albumin. As has been 
stated, it is associated with danger from the puncture of a large vessel in 
the tumor wall and the consequent hemorrhage; from the possibility of 



8o6 GYNECOLOGY. 

infection by escape of the contents of a papillary cyst or the rupture of a 
thin-walled cyst and the escape of its contents into and over the peritoneal 
cavity; or, lastly, from septic infection. Puncture may be resorted to as a 
temporary measure in a tumor complicating pregnancy, when the cyst 
is so situated as to form an obstruction to labor, and then should be per- 
formed through the vagina, after the most thorough cleansing of that canal. 
Puncture of a cyst through the rectum, under any circumstances, is an 
unjustifiable procedure. 

344. Ovariotomy, as the operation for extirpation of the tumor is 
known, is the only operation worthy of consideration as applicable to all 
cases. Success in its performance will depend very much upon the care 
with which the diagnosis has been made, the knowledge of the operator 
as to the condition of the patient, the dexterity with which the operation 
is performed or the readiness in meeting complications, and the judicious 
treatment of the patient subsequently. 

Indications. Recognition of the danger in any operation upon the 
peritoneum led the early operators to postpone interference until the patient 
had begun to experience marked discomfort and was suffering in general 
health from the pressure of the growth. Acceptance of the principles 
of antisepsis and asepsis has rendered postponement unnecessary. A more 
careful study of the progress of the growths has demonstrated that it is 
unwise to postpone operation after a tumor has attained a growth sufficient 
to permit of diagnosis, because of the various complications which may 
develop. A large proportion of ovarian tumors are of a malignant char- 
acter. Schultze places the proportion of malignancy at 27 per cent, of all 
ovarian tumors; Ruge, at 15 per cent. These variations are dependent 
upon their appreciation of the relation of papillary formations to malig- 
nancy. Pfannenstiel found, among 400 cases in which were included 
parovarian tumors, that 19 per cent, were malignant. Reckoning the 
papillary adenomata, the number equaled 26.15 per cent. — a proportion 
agreeing with the estimates of Schultze and Leopold. It will be seen from 
these statements that about every fourth or fifth ovarian tumor may be 
considered malignant. The diagnosis of malignancy cannot be made 
with certainty. If it is recognized that safety in these cases lies in the 
earliest possible extirpation, it will be evident that in one-half of all the 
cases the early extirpation of the tumor will be indicated. Absolutely 
benign growths of the ovary are unlimited in their size, and thus cause 
symptoms which imperil the life of the patient and lengthen the time re- 
quired for recovery. Delay favors the development of complications 
which, if they do not threaten life, create conditions that render the later 
operation more difficult and the prognosis less certain. These circum- 
stances, with the present favorable prognosis of ovariotomy, render it 
desirable that every ovarian tumor should be subjected to operation as 
soon as it attains a size sufficient to permit of its diagnosis. It was formerly 
advised to wait until the tumor had reached a size that would permit it 
to rest upon the pelvis, but no limit is now known, and the operator 
prefers to remove the tumor as soon as the patient's permission can be 
secured. The inability to determine the exact character of the growth, 



OVARL\X TUMORS. 807 

and the possibility of very small papillary tumors infecting the entire 
abdominal cavity, make early operation advisable. 

The severity of the symptoms only come into consideration by pro- 
moting the early decision of the patient for operation. The difficulties 
of the operation should not be a cause for delay, as they will not become 
less by waiting. The stage of life plays no role in the decision unless the 
growth is complicated by acute tubal disease, which may render temporary 
delay desirable. 

The indication for operation should be considered as urgent when the 
tumor begins to grow rapidly or when symptoms of threatening complica- 
tions appear. Compression of the lungs, symptoms of uremia, of ileus, 
of intraperitoneal or intracystic hemorrhage, or rupture of the cyst must 
be considered as urgent and vital indications. More frequent complica- 
tions are torsion of the pedicle and inflammation and suppuration of the 
cyst. The existence of peritoneal irritation has been considered as a 
reason for delay in operating, but now we realize that the patient has a 
much better prognosis through early operation than when it is delayed. 

Contra-indications . The reasons for withholding operation may be 
transitory or permanent; the former, in severe complicating diseases, as 
intercurrent fevers, bronchial catarrh, especially in the aged, progressive 
weakness from loss of blood, or obstinate gastro-intestinal catarrh. The 
menstrual period is sometimes regarded as such a cause, but as it does not 
increase the danger of infection, it is no bar. The permanent contra- 
indications are: irrecoverable disease of the heart, lungs, kidneys, or 
liver, marasmus, especially senile, and such diseases as will in a short 
time certainly lead to death. WTiile pulmonary tuberculosis, valvular 
disease of the heart, and nephritis are contra-indications, ovariotomy oc- 
casionally lessens the danger from the lesion. 

Age is no contra-indication, as a number of successful operations after 
the age of eighty are reported. The mortality of loo cases operated upon 
after the age of seventy was 12 per cent. (Kelly). Ovariotomy is not 
contra-indicated by age unless the tumor is associated with some disease 
which will render death certain in a short time. 

A number of anatomic contra-indications were formerly recognized, 
among which were adhesions, intraligamentary growths, or the existence 
of malignity. Adhesions are no longer considered a reason for delay, and 
frequently the relation of the tumor to the broad ligament is discovered 
only during the operation. In the majority of cases the attempt at the 
operation only terminates with its completion, \\Tiile the most trifling 
hope of recovery exists, and no traces of cachexia and metastasis formation 
are present, the operation should not be considered as contra-indicated. 

General Considerations. Unless immediate operation is indicated by 
torsion of the pedicle, rupture of the cyst, or indications of cystic hemor- 
rhage, two days should be occupied in the preparation of the patient, 
during which the pulse, temperature, condition of the respiratory organs, 
and urine can be studied. In complicated cases the procedure may be 
longer delayed, until the condition of the patient can be corrected. In 
very large cysts, with marked edema and dyspnea many authors advocate 



8o8 GYNECOLOGY. 

a preliminary puncture, in order that the lungs and kidneys may have a 
few days to recover their functions before the major operation is performed. 
Because of its many disadvantages, puncture should be done very in- 
frequently. For the performance of ovariotomy the following assistants 
are desirable: First, a principal assistant, who stands opposite the operator; 
second, the anesthetist; third, a nurse or a physician to arrange and serve 
the ligatures and sutures; fourth, a second nurse, to serve and count the 
gauze pads; and fifth, a nurse to serve in changing the water for the hands 
of the operator and his assistant and for collecting and counting the soiled 
pads. All these persons should be. trained to know and to do their duty. 
Directions as to their preparation for the operation are given. (§129.) 

Instruments. A knife, two pairs of scissors, two long dissecting forceps, 
twelve small and six large clamp forceps, two ligature carriers, a needle- 
holder, an angiotribe, a trocar, a tube, two pairs of cyst forceps, and two 
short and four long curved needles, each threaded with a double silk loop 
for carriers, should be provided. The instruments should be carefully 
sterilized and placed in sterile trays. The patient should be placed upon 
a suitable table, with her feet toward a good light. An ordinary kitchen 
table will serve well. The operator stands at the patient's left and his 
assistant opposite. To the right of the operator is a table, upon which are 
placed the tray containing the instruments; a smaller one, for the needles 




Fig. 582. — Cyst Forceps. 

and ligatures; and a basin with sterile water, for the hands of the operator. 
This should be changed as often as it becomes soiled. Behind the princi- 
pal assistant stands another table, on which are placed the gauze pads and 
dressings. The soiled pads are collected and counted when the operation is 
completed. It is important that the exact number shall be known, and 
that all be accounted for before the wound is closed. When dry pads 
are used, it is a good plan for the nurse to have a definite number, say a 
package of twelve, placed in a basin, and no more opened until these are 
used. As the pads are withdrawn they should be placed aside in packages 
of the same number, which m.akes the enumeration of the sponges easily 
made and the number wanting easily determined. Want of care may 
result in the retention of a pad, or even an instrument within the abdominal 
cavity, to the detriment of the patient and the discredit of the surgeon. 
There should be on hand in the room hot and cold sterilized water, — at 
least five gallons of each,^ — slop-buckets, a normal salt solution for irriga- 
tion of the abdominal cavity, and a suitable apparatus for hypodermoclysis 



OVARIAN TUMORS. 



809 



or intravenous injection, should the condition of the patient demand it. 
In addition, there should be within the reach of the anesthetizer a hypo- 
dermic syringe and solutions of strychnin and atropin, gloinin, and anti- 
septic ergot. 

The operation is best described by dividing it into stages and detailing 
the method of procedure in each. The student can thus secure a graphic 
outline of the various accidents which may possibly occur and of the ex- 
pedients to which he will find it best to resort as he proceeds. He will 
be unlikely to mistake his course on the journey if an accurate chart of 
each portion is furnished him. 




Fig. 583. — Wall Incised; Cyst Exposed. 

The different stages are: 

1. Incision of the abdominal wall in the median Une or through one 
rectus muscle, .securing all bleeding vessels with hemostatic forceps be- 
fore the peritoneum is opened. (§140.) 

2. Puncture and evacuation of the cyst. 

3. Removal of the cyst and management of the adhesions. (§145.) 

4. The method of controlling the circulation through the pedicle. 

5. Examination of the other ovary and of the general peritoneal cavity 
for bleeding vessels; the removal of all gauze pads. (§146.) 

6. Drainage. (§147-148.) 

7. Closure of the w^ound. (§148.) 

8. Dressing. (§149.) 

I. Incision of the Abdominal Wall. Great care was exercised formerly 
to open the abdominal cavity in the linea alba and not expose 
the structure of either rectus, but now I prefer to expose the one muscle 



8io 



GYNECOLOGY. 



and draw it over so that the incision in the posterior fascia is along its 
inner edge. Less hemorrhage thus results than when the incision passes 
through the structure of the muscle. The union resulting from the wound 
made through the linea alba would produce a feeble and resisting ven- 
trum. When there has been previous separation of the recti muscles as 
a result of the extension, I prefer to expose both recti and so introduce the 
sutures to hold them and their aponeurotic capsule in accurate apposition. 
The linea alba is the weakest part of the abdominal wall. The peri- 
toneum is picked up, pulled away with two pairs of forceps from the tumor 
wall, and an incision is made through it. This avoids injury to the tumor 
wall or to a knuckle of intestine should it be situated over the cyst. The 




Fig. 584. — Cyst Punctured and Being Withdrawn. • 

peritoneum is incised the length of the wound so that it will not be likely 
to be pushed off during the subsequent manipulation. 

2. Puncture and Evacuation of the Cyst. The incision completed and 
bleeding vessels clamped, the surface of the tumor is explored to determine 
the presence and extent of adhesions. They should be broken or sepa- 
rated to permit the exit of the superficial portion of the tumor. Various 
more or less ingenious trocars have been devised for evacuating the con- 
tents of the cyst. What is required is a cannula with a tube attached, 
through which the fluid may be carried to a receptacle beneath the table. 
The simpler and more readily cleansed this apparatus, the better. A glass 
nozzle for a fountain syringe, with three feet of rubber tubing, will serve 
very ^^well. A glass tube of larger caliber will prove more effective when 
there is a large quantity of fluid to be evacuated, or where the fluid is very 
viscid. In a specially prepared operating room a cannula, however, is 



OVARIAN TUMORS. 



8ll 



not a necessary part of one's equipment, for the cyst contents may be 
readily evacuated through a knife thrust, but at the expense of greater 
soiUng of the room and clothing. 

The point chosen for puncture should be situated toward the upper 
portion of the wound, so that the contraction of the emptying cyst will not 
draw the opening within the abdomen. The principal assistant should be 
directed to make pressure upon the abdomen so that the cyst as it empties 
shall be forced toward the abdominal opening. The edges of the cyst 
wound can be seized with hemostatic or cyst forceps and drawn out, 
serving as a funnel as the cyst empties, and before it is completely emptied, 
unless fixed by adhesions, withdrawn from the abdominal cavity. When 
the cyst is a large one, I would advise that the patient be turned upon her 




Fig. 585. — Withdrawal of Sac, Showing Adhesions. 

side, the assistant making firm pressure to keep the cyst pressed into the 
wound as it empties. This position favors the rapid evacuation of the 
cyst contents, with the least danger of the entrance of the fluid into the 
peritoneal cavity. When the operator has provided himself with sterile 
basins, he can collect the fluid and obviate soiling of the body of the patient, 
her sterile evironment, and the room with its contents. The lateral 
position also is favorable in necrotic cysts, as it permits their removal with 
less soiling of the general peritoneal cavity. The precaution to obviate 
soiling the peritoneal cavity is especially important when the cyst contents 
are purulent. The careful observations of Watkins have demonstrated 
that the contents of these cysts often are especially virulent, producing 
fatal peritonitis or other form of sepsis whenever the infection has found 
lodgment within the abdomen. Large vessels in the cyst wall should be 
avoided in making the puncture, while entrance of the cyst contents into 
the abdominal cavity can be prevented still further by placing gauze pads 



8l2 GYNECOLOGY. 

between the cyst and the edges of the wound. The operator, by seizing 
the edges of the cyst wound and forcibly drawing them out emptied, pro- 
tects the peritoneal cavity from any soiling, especially when the patient 
occupies the lateral position. When a cannula is used, the relaxed cyst 
upon either side of the cannula is caught with suitable forceps and drawn 
out. In nonadherent cysts this procedure will permit the removal of the 
sac, when empty without any soiling of the abdominal cavity. In multi- 
locular cysts the largest cyst exposed is first evacuated, through which 
succeeding cysts may be then emptied, drawing the first out to serve as a 
funnel. Areolar and dermoid cysts are best removed without effort at 
their reduction, because the contents, especially of the latter, are irritating 
to the peritoneal cavity and difficult to remove from it. Occasionally, 





Fig. 586. — Ligatures Introduced through FiG. 587. — Interlacing of Sutures to Prevent 

Broad Pedicle. Splitting of Pedicle. 

the cyst-contents are so viscid that they refuse to run through the cannula. 
The edges of the puncture are seized and the sac is drawn forcibly against 
the wound, while the opening is enlarged and the jelly-like contents are 
scraped away. 

3 . Removal of the Cyst and the Management of A dhesions. In non-adherent 
cysts the tumor is already delivered, but in the presence of extensive 
adhesions its delivery may be attended with the greatest difficulty and the 
gravest peril. The aim, as far as possible, should be to separate old ad- 
hesions under the eye. Recent adhesions frequently can be separated 
by a pad pressed against them as the sac is drawn out, or the hand may 
be passed into the abdomen over the tumor and thus quickly separate 
the recent adhesions. In old cases with extensive adhesions the conditions 
are different and it is unwise to separate adhesions except under sight. 
This purpose may require a much longer incision to permit of the 
adhesions being treated under the eye. The adhesions, where possible, 
should be torn, but where this is not feasible, they may be cut with 
scissors or knife, making sure that large vessels are secured. Oc- 
casionally the adhesions are so short or the contact so close between 
the cyst and coils of intestine that the separation is impossible. The 
cyst wall may be cut through, leaving a portion attached, resembling 
a patch. Care must be exercised, however, to remove all secreting sur- 
faces from the lining membrane of the cyst. Great care must be exercised 



OVARMX TUMORS. 813 

in separating old adhesions, as large vessels in the omentum, mesentery, 
and pelvis may be torn, producing severe or even fatal hemorrhage. In- 
juries to intestines, bladder, spleen, or liver may occur, which if overlooked, 
produce fatal results. A\Tien the tumor has been delivered its pedicle, if 
sufficiently long, should be clamped and the mass removed. A hasty 
glance is then given to the condition of the viscera where dense adhesions 
have been separated, to make sure that adhesions have not occurred which 
will cause serious hemorrhage or permit the soiling of the peritoneal 
cavity with the contents of intestine or bladder. 

4. Management of the Pedicle. If the pedicle is long and thin, a liga- 
ture may be thrown around it and tied. The stump should be folded un- 
der in order that it shall not form adhesions with the coil of intestine. 




Fig. 588. — Sutures Interlaced and Tied. 

In a short, broad pedicle this is not feasible, but the section method, 
illustrated by Figs. 586, 587, and 588, serves an excellent purpose. 

When tied in several sections the ligatures should interlace, in order to 
prevent the pedicle from splitting, and the peritoneum should be sutured 
over the stump. This procedure takes additional time, but often will 
save the patient from very uncomfortable if not dangerous adhesions 
between the stump and intestine. The Downes electric angiotribe affords 
an excellent method of securing against hemorrhage, and leaves the wound 
without the irritation of a foreign body. In a cyst without a pedicle the 
sac should be enucleated and the vessels secured as the operation proceeds. 
These cases present some of the most trying problems within the realm 
of abdominal surgery. In cutting away the tumor the precaution must 
be exercised to provide a sufficient button to prevent the ligature from 
slipping. If a ligature slips on a short, broad pedicle, the parts spread out, 
the vessels retract, and serious hemorrhage occurs, which may be difficult 
to control. Sometimes, when the pedicle has been tied ineffectually, 
the ovarian or uterine artery slips back and forms a hematoma in the stump, 
which so fills up the tissues as to make sufficient traction upon the ligature 
to withdraw the tissue and permit a fatal hemorrhage to follow. The 
tissue external to the ligature has a tendency to shrink after the removal 
of the tumor. This should not be forgotten, and when the traction is 
severe, a second ligature may be placed judiciously behind it to secure the 
ovarian artery. Silk, wire, and animal ligatures have been employed for 
securing the pedicle. Silk, from its strength, ease of preparation, and 
small amount of material required, is employed most frequently. I prefer 
chromic catgut, but the precaution must be exercised to tie it tight and to 
leave a secure button, because of its greater propensity to slip. Other 



8l4 GYNECOLOGY. 

methods of securing hemostasis have been employed : the vessels have been 
twisted; for many years the pedicle was brought out of the wound and 
clamped; Keith applied a temporary clamp and charred the tissues with 
the hot iron; Skene improvised a set of electrocautery clamps, by which 
the tissues were slowly burned through and the application of the ligature 
• avoided. This apparatus has been greatly improved and made practicable 
through the ingenuity of Dr. A. J. Downes, of this city. 

5. The next step was formerly described as the toilet of the peritoneum. 
Unless evidence of hemorrhage makes it incumbent to secure bleeding 
vessels, the next procedure should be to inspect the other ovary which 
frequently will be found to be the seat of disease, often completely 
involved by a glandular, papillary, or dermoid growth. Where necessary, 
it must be removed, but if possible (unless in mature women), a portion 
of the organ should be saved. The deprivation of the possibility of pro- 
creation is too serious a matter in young women to justify the needless 
sacrifice of ovarian structure. In many cases, even when associated with 
large tumors, a portion of the ovary capable of performing all the functions 
of that organ can be saved. Where adhesions have existed the omentum, 
mesentery, and pelvis should "be inspected carefully for bleeding vessels, 
and any such should be secured. Wherever possible the peritoneum 
should be sutured over torn and denuded surfaces, clots of blood removed, 
and ragged edges left from adhesions cut away. Should oozing occur from 
a large surface, it may be controlled by infiltration of the tissue with i to 
4 of a 1 : 1000 solution of adrenalin chlorid in sterile normal salt solution 
through a hypodermic syringe. Should this procedure be ineffectual and 
the surface too large to permit it to be quilted together with a continuous 
catgut suture, a gauze pack may be employed. The pack has the ad- 
ditional advantage in extensive denudation that it keeps the intestines 
from contact with the raw surface until the peritoneum has had an 
opportunity to re-form and thus prevents the redevelopment of firm ad- 
hesions. It is true, the packing becomes walled off, but the adhesions 
thus formed are soon absorbed after the removal of the gauze, unless the 
patient has become infected. The end of the pack can be brought out at 
the lower angle of the wound, but the drainage is against gravity, frequent 
dressing of the wound is required, the danger of infection is increased, 
and a weakened ventrum results in an increased susceptibility to sub- 
sequent hernia. For these reasons it is preferable that the end of the drain 
be carried into the vagina and the gauze be ultimately removed through 
that canal. Drainage by the vagina presupposes that the vagina has been 
sterilized as a preliminary to the operation. Should this have been neg- 
lected, the gauze packing may be placed in the pelvis and the wound 
closed, making an incision through the posterior vaginal vault, which 
easily can be done for its removal. All wounds penetrating the intestine 
or bladder should be sutured as soon as discovered in order to prevent the 
peritoneal cavity from being soiled by their contents. Wounds in the 
peritoneum, as far as possible, should be sutured. When the omentum 
has been torn, making a ragged, stringy margin or opening in its structure, 
it should be ligated and the portions external to the ligature excised. 



OVARIAN TUMORS. 815 

Otherwise a coil of intestine may slip through such an opening or beneath a 
band and become strangulated. The peritoneal cavity should be cleansed 
of blood and cyst contents, preferably by sponging with dry gauze, 
but when there are large denuded surfaces, or the peritoneum has been 
soiled with irritating fluids as from a dermoid or suppurating cyst, the 
cavity should be irrigated with normal salt solution, filled with the solution, 
and closed. The fluid permits the intestines to float, allows the regenera- 
tion of the denuded epithelium, and lessens the danger of unfortunate 
adhesions. As a final consideration before closing, the surgeon should be 
certain that the abdominal cavity contains no foreign material, such as 
gauze pads or instruments. Directions have been given for keeping tab 
upon the number of pads used and of insuring the certainty of their re- 
moval. The surgeon should not rely wholly upon the nurse, but should 
be certain that he has removed all the pads he has inserted. It is a good 
plan to wall off the intestines with a long and wide piece of gauze first and 
place the smaller pieces, when necessary, below it. 

6. Drainage. This subject is no longer granted the importance in 
abdominal work it was vouchsafed when I first began the practice of 
surgery. Then the profession gave heed to the admonition of Tait: 
"When in doubt, drain." Experience has taught the wonderful power 
the peritoneum possesses of protecting itself, and, outside of a vaginal 
wick, drainage is rarely employed. The gauze wick has supplanted the 
glass drainage-tube. Twenty-five years ago I frequently introduced the 
glass drain, but have not used one in several years. In extensive denuda- 
tion of the pelvic peritoneum associated with oozing the gauze tampon is 
of value. In repair of the large intestine in its lower portion, especially 
where the tissues sutured are more or less friable from inflammatory 
changes, it is wise to cover the surface loosely with gauze in order to afford 
a vent should union fail and a fecal leak occur. The gauze drain, when 
possible, should open into the vagina and be removed through it. The 
drain should be permitted to remain from four to six days. The most 
effective drain for the pelvic peritoneum is the gauze rope brought out 
through the vagina and the use of the Murphy instillation of salt solution 
while the patient occupies the Fowler position. (See Peritonitis.) 

7. Closure of the Wound. The aim of the operator is so to close the 
wound that like surfaces shall be brought in apposition, and afford as 
little opportunity as possible for the accumulation of fluids (serum or 
blood) in the wound. After prolonged observation of different methods 
I have chosen the procedure described in Section 148 as the most satis- 
factory and the least likely to be followed by hernia. The one flaw in this 
procedure is the possibility of serum or blood collecting between the peri- 
toneum and muscle and its infection from its proximity to the intestinal 
canal. Should the patient after operation have a continuous elevation of 
temperature for which no explanation is apparent, it will be wise to make 
a puncture to ascertain the existence of an extraperitoneal collection, when 
early evacuation saves a weakened ventrum. 

8. Dressing. The wound dressing should be simple and unirritating. 
The wound surface should be free from pathogenic germs and protected 



8i6 



GYNECOLOGY. 



from them until recovery has followed. The silkworm-gut sutures are 
left long, the wound is sponged with 50 per cent, solution of alcohol in 
sterile water, then covered lightly about the suture ends with gauze, then 
several layers of gauze, and finally a pad of wood cotton and gauze held in 
place with pieces of plaster to which tape is attached to be tied over the 
dressing. The whole dressing is then secured by a Scultetus binder. 
This method of securing the dressing affords easy access to the wound 
with little annoyance, to the patient. 

General Considerations. The study of the differential diagnosis of 
ovarian tumors should have prepared the operator to appreciate the fact 
that, after the most careful investigation of his cases, he must frequently 
expect to meet with conditions entirely different from those which the 





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A 




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m 


1 


% 


t^^ 


.^f 
^\)^^' 


1 


LIGATURE M| 
ONOl/ARiAN,^K 


7 


. *«5/' 








■iK-,v , ,,>',„ 




i. 


^..^ 







Fig. 589. — Splitting of Pedicle when Sutures are Tied without Interlacing. 

physical signs have indicated. What appears a simple ovarian cyst may 
present complications which test the ingenuity of the most experienced 
operator. The inexperienced operator should prepare himself for every 
emergency, and should have previously planned for them, as the prudent 
general plans for the coming battle. The more carefully the case has been 
studied, the patient prepared, and the emergencies anticipated, the more 
certain will be the success. It is far better to go through unnecessary 
preparations many times than to be unprepared once. 

Patients with large ovarian cysts frequently suffer from pressure 
symptoms, and are greatly benefited by previous purgation, stimulation 
of the secretion of the kidneys and skin, and the administration of strychnin 
and atropin to strengthen the action of the heart and vessels. In the in- 
cision care is exercised to avoid pushing off the peritoneum and to escape 



OVARIAN TUMORS. 817 

injuring the bladder, a loop of intestine, or the cyst. The bladder may 
be drawn up to a higher level by adhesions to the cyst. It is recognized 
by the arrangement of the muscle-fibers in its wall. The parietal peri- 
toneum is occasionally inseparable from the surface of the tumor along the 
line of incision, when the cyst may be opened and emptied before proceed- 
ing to the separation of the adhesions. 

The intestine is rarely in danger of injury during this stage of the 
procedure, but occasionally a loop may be situated in front of the cyst. 

The toilet of the peritoneum should not be understood to mean thor- 
ough drying of the cavity; indeed, much sponging and manipulation of the 
peritoneum are injurious and favor the formation of adhesions. The 
cavity is most readily cleansed, with the least injury, by irrigation with 
normal salt solution. The retention of a considerable quantity of the 
fluid is beneficial, in that it favors peristalsis, and by its absorption re- 
plenishes the liquid waste. Ragged omentum and shreds or bands of 
adhesions should be removed. When the irrigating fluid continues to 
come away bloody, careful examination should be instituted to ascertain 
the source of the bleeding. The abdomen must not be closed while a con- 
siderable quantity of blood is being lost. Unless the abdomen has been 
soiled with infective cyst contents it is better not to irrigate. If the pre- 
caution has been exercised to protect the cavity by gauze packing, irri- 
gation seldom will be required. A saline solution is probably the least 
irritating of any introduced into the peritoneal cavity, but even it handi- 
caps to some degree the functions of this extensive absorbing surface. 

Post-operative Treatment. (§150-164.) 

Incomplete Operation. The conditions in which the operation has not 
been completed are most frequently those of intraligamentary parovarian 
cysts, and particularly papillary cysts. The structure of the broad ligament 
is more or less involved, and not infrequently adhesions affect a large 
portion of the intestine. The more experienced the operator, the less 
frequently will the incomplete operation be performed. With judicious 
measures, cases in which the operation cannot be completed are exceed- 
ingly rare. In the intraligamentary variety an incision of the peritoneum, 
where it is situated about the base of the tumor, is made, the tumor is 
drawn up, forming a pedicle, and the tissue is pushed off by blunt dissec- 
tion. Sometimes the tumor may be opened and an incision made at its 
base, by which the sac is then dissected out. Frequently it is advisable 
to precede the operation by ligation of the larger vessels, particularly the 
ovarian arteries, after which the dissection can be accomplished with less 
hemorrhage. Adhesions, when in the form of cords and bands, may be 
cut with the Paquelin cautery. In the papillary variety it is very impor- 
tant that the mass should be removed, even if it is necessary to extirpate the 
uterus to accomplish it. Frequently what seem desperate cases recover 
when the original source of the disease is removed, even though extensive 
infection of the peritoneal cavity has occurred. When adhesions are 
extensive and the condition of the patient is such as to preclude the possi- 
bility of complete removal of the sac, the cavity should be emptied, 
cleansed, and sutured to the parietal peritoneum of the abdominal wall. 



8l8 GYNECOLOGY. 

while the remaining portion of the wound is closed. The sac cavity is 
packed with iodoform gauze. Thus it may be kept open, irrigated from 
time to time with disinfectant solutions, and the packing renewed until the 
cavity fills by granulation. This procedure necessarily is attended with 
increased danger to the patient, as it is impossible to keep such a wound 
completely aseptic. 

When a tumor is situated deep in the pelvis, the abdominal opening 
may be closed after an incision has been made through the base of the 
tumor into the vagina, through which the end of the gauze packed into the 
cyst may be carried. Over this gauze the cyst-wall is closed, and covered, 
when possible, with peritoneal flaps. Intraligamentary tumors are some- 
times pushed up into the mesentery, and the removal of the mass necessi- 
tates the ligation of important branches of the mesenteric artery. When a 
large portion of mesentery is thus ligated, the vitality of the portion of in- 
testine supplied by it is endangered and gangrene of the gut may result. 
Such cases may demand the excision of the affected portion of the intestine 
and an end-to-end anastomosis. In metastasis of the papillary variety 
into the omentum, forming, as it frequently does, good-sized masses in- 
volving the entire omentum, the latter should be removed after ligation of 
its base with a number of catgut ligatures. In a patient who had double- 
sided papillary ovarian cysts, with extensive ascites from the infected peri- 
toneum, and had been subjected three times to abdominal section for the 
evacuation of this fluid, it was my privilege to remove both ovaries and 
the greater part of the uterus after an extensive dissection. The entire 
omentum also was removed. This patient, in whom the dropsical effusion 
had previously collected so rapidly that they were unable to get her out of 
bed after operation before the fluid had reaccumulated, had no recurrence 
of effusion subsequent to the complete operation, and two years later was 
in good health. 

Rupture of the Cyst. In cysts of the glandular variety which have 
been greatly distended, or where the pedicle is partly twisted, the cyst- 
wall becomes fragile and is torn easily, permitting its contents to escape 
into the abdominal cavity. This accident is not a serious one unless the 
cyst contents have undergone degeneration, as in suppurating cysts, or 
are irritating in character, as in the dermoid and papillary varieties. 
Tearing the cyst-wall will necessitate a thorough irrigation of the abdom- 
inal cavity to neutralize or to remove the contents. Where the contents 
of the cysts are quite viscid the peritoneal surfaces become so covered 
with the material as to make its complete removal impossible. Unless 
the sac is a malignant one, patients usually recover, and that without 
drainage. 

Hemorrhage. The site of the hemorrhage will greatly influence its 
character. In large cysts with extensive adhesions hemorrhage may 
take place from the cyst-wall or from vessels that have been torn 
within its walls and may threaten a fatal result. The adhesions should 
be separated rapidly, the cyst raised, and its pedicle secured to cut off 
the blood-supply. The larger and more vascular adhesions should be 
separated between ligatures or clamp forceps. If the hemorrhage threat- 



OVARIAN TUMORS. 819 

ens life, the assistant may place his hand within the abdomen, compress 
the abdominal aorta, and maintain the pressure until the operation is 
completed. Such a procedure prevents the further supply of blood, 
and so arrests the bleeding. Hemorrhage may occur from a very ex- 
tensive surface, particularly when malignant disease has been the subject 
of removal, or extensive papillary growths which are intraligamentary 
or behind the uterus. Fatal syncope and death may follow the removal 
of very large tumors as a result of decreased abdominal pressure. The 
vessels relieved from pressure become distended by the blood, and form 
extensive reservoirs, by which so much of the blood is withdrawn from 
the circulation as to cause cerebral anemia and the death of the patient. 
Such a patient can be said to have bled into her own vessels. Such an 
occurrence is likely to take place only in very large tumors, and may 
be obviated partly by emptying the cyst slowly. When syncope occurs, 
the head should be lowered, and an assistant may compress the abdominal 
aorta with the hand in the abdomen, while the treatment of the pedicle 
and the toilet of the abdomen proceed. Occasionally, it may be necessary 
to remove the uterus on account of the free bleeding from its torn and 
denuded surfaces. The vitality of the patient may be maintained by 
hypodermatic injections of strychnin, gr. 1/60-1/30 repeated three times 
at intervals of an hour, a i : 1000 solution of adrenalin chlorid, gtt. x — xv 
every hour, atropin, gr. i/ioo, to contract the. blood-vessels, ergone, 
TTj^xx, or a hypodermoclysis of normal salt solution. The salt solution 
can be poured directly into the abdominal cavity while the patient is in 
the Trendelenburg posture, or transfused directly into a vein. The latter 
measure affords an increased quantity of fluid by which the vessels can 
be filled and the heart have something upon which to contract. The 
fluid should be introduced slowly and 500-1000 cc. given to which has 
been added 4-8 cc. (i-iooo) solution of adrenal chloride. 

Visceral Injuries. Injuries to the intestine are possible during compli- 
cated operations. In making an abdominal incision the peritoneum should 
be raised with forceps and a small opening made, to prevent injury not 
only of the cyst-wall, but of a possible loop of intestine which may be ad- 
herent over it. This opening, in the peritoneum may be extended the full 
length of the external wound by holding it up and incising it under the 
eye. In dense adhesions the intestines may be torn into, or even across, 
during the process of their separation. When such a lesion occurs, the 
intestine should be repaired carefully at once, and measures taken to 
prevent soiling the peritoneal cavity w^ith the bowxl-contents. Openings 
in the intestine should be sutured carefully, and when the gut is injured 
so extensively as to render its vitality uncertain, resection and an end- 
to-end anastomosis should be done. This procedure is accomplished 
very quickly with the Murphy button or one of the many mechanical 
devices for holding the ends of the divided gut in apposition. In their 
absence, the anastomosis may be performed by the Connell suture which 
consists of a continuous suture beginning within the bowel, tying the knot 
so that it is in the caliber of the canal. This suture holds the peritoneal 
surfaces in contact and may be supplemented by an additional suture 



820 GYNECOLOGY. 

in the peritoneal surfaces. The continuous suture interlocking may be 
introduced and superimposed by a similar suture in the peritoneal 
covering. Such a closure is rapid and very effective. The closure may 
be made with fine silk or chromic catgut, or the internal may be made with 
the former and the external (or peritoneal) with the latter. 

The most difficult cases for suture are those in which the rectum 
has been torn low down in the pelvis. Portions of the bowel may be so 
devitalized that they will not hold subsequently, and a fecal fistula follows. 
In all cases in which the injury of the bowel has been extensive, and its 
condition endangered, the parts should be packed v/ith iodoform gauze, 
which affords a vent in case union is not complete. Complete closure 
of the wound should be interdicted, because the patieni would develop 
a dangerous peritonitis before the occurrence of rupture h recognized. 
The position and relation of the ureter should be kej't in mind in tumors 
situated low in the pelvis, or in those which are dc^ eloped in the broad 
ligament, and particularly in the papillary formL of ovarian growth, as 
the ovary may be pulled up or torn off in the enucleation of such masses. 
When the tumor is so situated as to endanger the ureter, it is better to 
expose the latter to make sure that it is uninjured. When it has been 
cut or torn, the preferable procedure is to establish an anastomosis be- 
tween the divided ends. (Fig. 249.) If this union is impracticable, 
then transplantation into the bladder should be practised. If the ureter 
is so short as to endanger its vitality by the necessary traction to reach the 
bladder the latter should be anchored to the side of the pelvis in a position 
most favorable to relieve the tension. The ureter may be introduced into 
the descending colon or an attempt may be made to introduce its end 
into the ureter of the opposite side; but one should hesitate in attempting 
the latter, as failure means the imperiling of the unaffected kidney and 
ureter. Its end may be brought out through the skin and a urinary 
fistula established, but this means an exceedingly uncomfortable con- 
dition for the patient. One alternative is to ligate the ureter, which should 
be done with double ligature, as a single ligature is likely, under the process 
of absorption, to become loose and permit a subsequent leakage of urine. 
The urine is secreted until the pressure from the distended pelvis is 
equal to that of the blood-pressure, when secretion no longer occurs. 
The unused organ becomes atrophied. 

Another alternative is nephrectomy, but the operator should be well 
assured that the remaining kidney is healthy before cutting one out of 
further usefulness either by ligation of the ureter or extirpation of the 
kidney. If the orifice of the kidney is brought out on the back, a recep- 
tacle may be fitted which will add to the patient's comfort. 

The bladder may be injured during an operation. It may have been 
drawn up over the anterior surface of the tumor and raised so high as to be 
incised or its fundus may be removed before the true character of the 
injury is suspected. The peculiar interlaced muscular structure of the 
bladder- wall should permit its recognition. When it is opened or injured, 
it should be sutured. In a case of fibroid tumor in which it was my 
misfortune to cut away the entire summit of the bladder the walls were 



OVARL\N TUMORS. 82 1 

sutured, and the patient recovered. In such cases it is important that 
the bladder should be watched to prevent its becoming unduly distended 
during convalescence. It should be evacuated frequently in order to 
avoid separation of weak union and leakage of urine. 

Prognosis. The result of ovariotomy will depend greatly upon the 
manner in which it has been conducted. With the exercise of every 
precaution, there will frequently be cases of delayed convalescence, owing 
to latent or preexisting pathologic conditions; but the danger is greatly 
increased when the operation has been carelessly performed and its details 
imperfectly practised. The operator and his assistants should have 
been so well trained that no deviation from the proper course, even though 
slight, will be overlooked. WTiat avails the most rigid cleanliness of 
person, room, and instruments when a ligature is employed that has been 
dragged over blankets or unclean tables before its introduction ? when 
the wound is dusted with iodoform from a box that has been standing 
open, or has been used in all sorts of cases about a ward ? when the opera- 
tor rubs his nose, scratches his head, or touches nonsterilized objects, 
and introduces the hand into the abdominal cavity without precautionary 
cleansing? Such indiscretions are often responsible for stitch abscesses 
and other septic processes. Pus-collections and cellular inflammations 
in the pelvis in the region of the uterus frequently result from infection of 
serous collections in Douglas' pouch. Elevation of temperature, rapid 
pulse, and abdominal tenderness subsequent to the fourth or fifth day 
should lead to careful exploration for their origin. A mass of exudate 
in the pelvis should be considered an indication for vaginal incision, 
for the administration of salines until free purgation is secured, and for 
the use of rectal and vaginal enemas of hot water at least twice daily. 
The vaginal incision should be a free one across the vault of the vagina, 
after which the cavity should be irrigated thoroughly with normal salt 
solution and an efficient packing of iodoform gauze introduced. Careful 
sterilization of the vagina should precede the operation. 

Intesthtal Complications. In difficult operations inflammatory in- 
testinal sequels are frequent. The intestines may be obstructed by 
twists, and this danger is aggravated by bands of inflammatory adhesions, 
or by openings in the omentum or mesentery, through which a knuckle 
of intestine may slip and become strangulated. Lacerations of the intes- 
tinal coat affect the peristaltic action, and may lead to paralysis of a 
section, with ensuing symptoms of obstruction. A twist or volvulus may 
become so fixed that nothing will pass it. In walls that are already 
weakened a fecal fistula will result. In a case some years ago in the 
Philadelphia Hospital an operation by a colleague was followed five 
weeks later by symptoms of obstruction, and the patient vomited stercora- 
ceous material. The abdomen was reopened and five feet of intestine 
were torn up, disclosing a distinct volvulus, which was untwisted, when 
the patient recovered after a prolonged convalescence. The importance 
of an early reopening of the abdomen in such a case cannot be overesti- 
mated, as the obstruction may be due to strangulation of a knuckle of 
intestine beneath inflammatory bands or to its inclosure between sutures 



82 2 GYNECOLOGY. 

of the wound. The latter is unlikely to occur when the wound is closed 
in the manner we have suggested. 

Causes of death after ovariotomy are, as in hysterectomy, shock, 
hemorrhage, and peritonitis. These sequels are less frequent, however, 
as the operation for ovariotomy is more easily accomplished and the dura- 
tion is shorter than in hysterectomy. Tetanus, which formerly occurred 
frequently after ovariotomy, is now extremely rare. Ileus may occur in 
the second week as a result of adhesions or twists of the intestine. Inability 
to accomplish the evacuation of the intestine by injections with the 
pelvis elevated, and especially when complicated with stercoraceous 
vomiting, should require the reopening of the abdomen. The mortality 
of ovariotomy is very slight^much less than formerly. This is partly 
due to the fact that operations are now performed early, and it is only in 
rare instances that the patients are subject to the deleterious action of 
the cyst. Early operation, before the patient experiences complications, 
is attended with very slight mortality. Thus, Martin, in more than looo 
ovariotomies, has but 2 per cent, mortality; Olshausen reported his last 
100 ovariotomies with only 4 deaths. The uncomplicated ovariotomy 
has practically no mortality. 



LIST OF AUTHORS QUOTED 



Abel, 105, no, III, 579, 675 

Abrahams, R., 225 

Adams, 474 

Ahlfeld, 521 

Alexander, 444, 472, 473, 474, 476, 490 

Alquie, 474 

Amann, 757, 762, 763 

Amussat, 209 

Andrews, 121, 123, 124, 128, 130, 278, 280, 

281, 282 
Apostoli, 150, 151, 152, 192. 195, 628, 629 
Aran, 368 
Arnold, 156 
Adee, 632 
Auvard, 218, 219, 232, 662 

Baccelli, 353 

Baer, 95, 646 

Baker, 700 

Baldwin, J. F., 210 

Baldy, 446, 479 

Bandier, 580 

Bandler, 139 

Barbour, 12 

Bardenheuer, 247, 713 

Barnes, 68, 70, 202, 534 

Barrett, 272, 275 

Barrows, 353 

Baruch, 138 

Basedow, 190 

Bassini, 475 

Baum, 222 

Bayle, 584 

Beatson, 137 

Beclard, 219 

Belfield, 51 

Bernhardt, 734 

Bernutz, 386 

Biegel, 598 

Bier, 360 

Billroth, 706 

Bischoff, 278, 279 

Bishop, E. Stanmore, 248, 249, 585, 641, 649, 

655,658 
Bissell, 479 
Bizzozero, 130 

Bland, P. Brooke, 166, 557, 665, 744, 745 
Blau, 678 
Bohmer, no 
Borelius, 722 
Bottini, 706 
Bouilly, 655 

Bovee, 223, 444, 485, 488, 490, 49 1> 7^5 
Bozeman, 241 
Brandier, 580 
Braun, 144, 230, 699 



Breisky, 312 

Brum, 125 

Bullitt, 767 

Bumm, 120, 125 

Burnham, 645 

Burri, 126 

Burrage, 459 

Butt, 144 

Byford, 18, 22 

Byrne, 153, 699, 700, 709 

Cabot, 131, 133 

Calderini, 706 

Camero, 329 

Carlo, 787 

Cassati, 476 

Chantreuill, 698 

Cheston, 534 

Chrobak, 733, 735 

Churchill, 145, 230 

Clark, John G., 30, 178, 328, 486, 708, 714 

Cleveland, 292, 294 

Cohnheim, 597, 683, 751, 784 

Cohnstein, 698 

Colpe, 345 

Congdon, 159 

Connell, 578, 819 

Coover, E. H., 137 

Coplin, 109, no, in, 112, 114, 115, 118 123 

Corneuil, 362 

Corradi, 707 

Corson, E. R., 245 

Court}', 67, 70, 498 

Cowper, 9, 308 

Cox, S. E., 568 

Crede, 713 

Cucca, 734 

Cullen, 666, 668 ,674, 679 

Cumston, 172, 738 

Curran, 223 

Curry, 118 

Czempi, 193 

Czerny, 701, 704, 706, 707, 709, 722 

DaCosta, John C, 581 

DaCosta, John C, Jr., 131, 133, 134 

Davidson, 156 

Davis, E. P,, 743 

Deaver, 4, 5, 10, 13, 14, 15. 34, 42, 81 

Delafield, in, 112 

DeSinety, 24, 344, 356, 361 

Dickinson, 229 

Doderlein, 116, 117, 119, 2,^,2, o2>^, 5^5 

Doleris, 131, 476 

Doran, Alban, 762, 763, 769, 783 

Downes, A. J., 153, 154, 414, 710, 813, 814 

Doyen, 652, 653, 659, 706, 760 



823 



824 



LIST OF AUTHORS QUOTED. 



Drszewczky, 738 

Dudley, A. P., 295, 296, 479 

Dudley, E. C, 445, 446, 447, 45^, 460, 478, 

479, 490, 650 
Diihrssen, 487, 708 
Duke, A., 426 

Dunning, 210, 359, 546, 552 
Duret, 426 
Diitzman, 133 
Dybowski, 678 

Eastman, Joseph, 412, 710, 713 

Edgar, 117, 128 

Ehler, 732 

Eiselberg, von, 583 

Ellinger, 95 

Emmet, T. A., 142, 231, 253, 272, 286, 287, 

. 292, 293, 345, 367, 393 
Ewing, James, 741 

Fabringer, 198 

Fenwick, 785 

Ferguson, 85, 88, 247, 248, 249 

Ferguson, A. H., 444, 479, 481, 483, 734 

Ferraresi, 206 

Finsen, 131 

Fisher, J. M, 538, 542 

Flemming, 109 

Flick, 322 

Fowler, 147, 184, 355, 404, 408, 815 

Fraipont, 733 

Franck, 709 

Frankel, 51, 128, 639, 733 

Freund, W. A., 127, 286, 290, 387, 445, 701, 

712, 713, 739 
Friedlander, 124 
Fritsch, 278, 282, 337, 362, 576, 706, 707, 725, 

733, 735, 737 
Frommel, 687, 709, 711, 724, 725 

Gant, 35 

Garrigues, 281, 285, 442 

Gehrung, 148, 628 

Geipell, 125 

Gellhorn, 734 

Gersterberg, 512 

Gessner, 751 

Gibb, W. Travis, 122 

Gilliam, 283, 444, 479, 481, 482, 491 

Goffe, 440 

Goldman, 675 

Goldspohn, 476 

Gooch, 361 

Goodell, 90, 92, 95, 734 

Gottschalk, 488, 639 

Gow, 646 

Grafenberg, von, 699 

Gram, 118, 119, 120, 123, 128, 310 

Grawitz, 125 

Greenhalgh, 546 

Gremlier, 580 

Grenach, 109 

Gross, 486 

Grlibler, 113 

Gubarroff, 714 

Guerin, 45 

Guiteras, Ramon, 307 



Gusserow, 585, 598, 684, 685, 689, 751, 752 
Guyon, 321, 328, 329 
Gwyer, Fredric, 735, 736 

Hare, Hobart A., 182 

Harmsen, 120 

Harrington, Chas., 160 

Harris, 102, 103, 112, 322, 330 

Hart, 12 

Hegar, 197, 280, 281, 285, 442, 582, 699, 700, 

701, 720, 722, 798, 799 
Heidenhain, 727 
Heinecke, 722 
Heller, 312 
Hennig, 26, 27 
Heppner, 285, 289 
Hermann, 35, 109, 678, 744, 746 
Herr, 253 
Herzfeld, 720, 722 
Hicks, Braxton, 546 
Higbee, 89 

Hildebrandt, 285, 288, 289 
Hirst, 523 

Hochenegg, 718, 720, 722, 724 
Hoffmann, 125 

Hofmeier, 584, 598, 642, 685, 726 
Holden, 563 
Houston, 35 
Houzel, 735 
Howe, 223 
Hunter, 584 

Jacobi, 486 

Jacobs, 412 

James, 546 

Johnson, J. Tabor, 122, 584 

Johnstone, 53 

Jones, Mary Dixon, 776, 783, 784 

Julien, 319, 546 

JuUiard, 133 

Jung, 109 

Kahlden, 751, 763 

KaiserUng, 114 

Kaltenbach, 707, 711, 726 

Kappes, 390 

Keen, 127, 200 

Kehrer, 735 

Keisel, 328 

Keith, 175, 183, 403, 814 

Kellar, 757 

Kelly, Howard, 100, loi, 102, 103, 328, 484, 

648, 649, 658, 707, 708, 709, 714, 807 
King, 547 
Kiwisch, 361 
Klebs, 128, 579, 683 
Klebs-Loeffler, 128 
Kleinhaus, 121 
Klob, 361, 584, 762, 765 
Kobelt, 10 
Koeberle, 645 
Koch, 123 
Koch, J. H., 130 
Kocher, 722 
Kohner, 198 
Konig, 39 
Koppe, 565 



LIST OF AUTHORS QUOTED. 



825 



Korff, 166 

Kraske, 571, 718 

Kronig, 116, 332, s^^^ 644, 716 

Krusen, 521 

Kuhn, 713 

Kummel, 782 

Kundrat, 716 

Kuster, 571, 592 

Kustner, 172, 502, 718, 787 

Landau, 415, 417, 685, 706, 760 

Langenbeck, 704, 709 

Langhan, 665, 741, 743 

Lauenstein, 19, 244, 262, 269, 278, 284, 287 

LeBec, 647 

LeClerc-Dauday, 329 

Leopold, 47, 209, 706, 726, 727, 728, 783, 806 

Levaditti, 126 

Levis, 146 

Levy, 127, 722 

Lewers, 684, 762 

Lieberkuhn, 35, 36 

Liebmann, 707 

Lindfors, 486 

Lisfranc, 65 

Loeflfler, 128 

Lustgarten, 125 

Lutaud, 327 

Luys, 328 

Mackenrodt, 487, 706, 708, 709, 716, 727 

MacClure, 180 

Maguire, 353 

Maier, Otto, 360 

Mann, 22, 330, 47/, 478, 488, 598, 625 

Mano, 130 

Marchand, 741, 743 

Marcy, 275, 502, 646 

Maritan, 767 

Mars, 312 

Mar h, 327 

Martin, A., 124, 285, 289, 290, 296, 297, 312, 

581, 639, 644, 650, 734, 735, 736, 738 

752, 822 
Martin, C, 50, 651 
Martin, Franklin, 346, 476, 485, 639 
Matthews-Duncan, 385 
Maydl, 724 
Mayo, Charles H., 125 
Mayo, William J., 125 
McBurney, 330 
McCosh, 407 
McCannon, M. C, 246 
Menge, 116, 149, 194, 332, s^s> ^44, 7i7 
Meyer, 124 
Mickwitz, 787 
Mikulicz, 177, 706 
Mitchell, S. Weir, 369, 385 
MoUer, 598 
Monsell, 306 
Morrow, 122 
Moschowitz, 159 
Mosetig-Moorhof, 734 
Muir, 120 

Miiller, Peter, 584, 707 
Munde, 227, 228 
Murphy, 184, 355, 404, 815, 819 



Napier, 53 

Natvig, 117 

Neisser, 120, 121, 334 

Nelson, 90 

Neugebauer, 579 

Newman, Henry, 475, 710 

Nitze, 100 

Noble, Charles P., 275, 287, 447, 539, 742 

Noble, George H., 277 

Noeggerath, 361 

Northrup, 167 . - 

Nott, 89, 90 

Nourse, 459, 461 

Obermeyer, 134 
Ohlmacher, 329 
Olshausen, 484, 486, 598, 706, 707, 725, 726 

732, 803, 804 
Orth, III 

Orthmann, 124, 125 
Osier, 125 
Outerbridge, 290, 294 

Paget, Sir James, 754 

Pankau, 133 

Pawlik, 100, 708 

Pean, 410, 640, 709 

Peter, 312 

Petit, 578, 659 

Pfannenstiel, 127, 747, 777, 806 

Pfluger, 28, 207 

Pick, 109, 743 

Plouquet, 780 

Poirier, 728 

Polk, 37, 625, 715 .... 

Pozzi, 6, 94, 165, 204, 219, 237, 561, 696, 701, 

765 
Pratt, 96, 106, 368 
Price, M., 530 
Prochownik, 521, 598 
Pryor, 73, 119, 195, 413, 4^8, 648, 658, 678 

ReckUnghausen von, 597, 761 

Reed, C. A. L., 123, 275, 459 

Reed, E. L., 568 

Reich, 707 

Rein, 50 

Reyburn, 684 

Riberts, 683 

Ricard, 733 

Richelot, 654, 709 

Ricker, 751 

Ries, 444, 479, 488, 678 

Ristine, 277, 278, 279 

Ritchie, 120, 761 

Robb, 155 

Roberts, 123 

Robertson, 54, 547 

Robinson, 331 

Robinson, Byron, 642 

Rokitansky, 762, 770 

Rontgen, 151, 152, 735, 736 

RosenmuUer, 26, 31, 36, 704, 764, 766, 768 

Ross, 684 

Rossing, 328 

Rosthorn, von, 124, 716 

Royster, 223 



826 



LIST OF AUTHORS QUOTED. 



Ruge, 334, 355, 671, 806 
Rumpf, 714 
Rydygier, 722 

Sanger, 128, 237, 253, 276, 615, 706, 726, 734, 

735. 761, 762, 764, 766 
Sanger-Barth, 761, 763 
Sappey, 22, 24 
Sauter-Recamier, 704 
Savage, 9, 12, 17, 18, 20, 33, 41, 43, 44, 45, 46, 

47 
Saxonia, 54 

Scanzoni, 361, 367, 785 
Scarpa, 390 
Schaefer, 387 
Schaeffer, 152, 188, 191 
Schatz, 706, 711 
Schaudinn, 125 

Schauta, 621, 678, 706, 716, 723 
Schede, 720, 724 
Schlagenhaufer, 741 
Schlange, 722 
Schleich, 103, 169 
Schmidt, 486, 487 
Schmorl, 125 
Schnabel, 780 
Schneiderlin, 166 
Schramm. 734 
Schroder, 3, 20, 233, 234, 235, 346, 359, 368, 

579, 585, 592, 642, 645, 687, 689, 699, 

701, 706, 707, 715, 754 
Schuchardt, 707 
Schuking, 487, 577 
Schultze, 147, 149, 387, 467, 468, 470, 471, 

734, 806 
Schwank, 741 
Schwarz, 352, 683 
Seelig, 675, 676, 701 
Seligman, 310, 312, 760 
Segond, 410 
Semmelweis, 348 
Shimer, A. B,, 656, 657 
Shoemacher, 598 
Siebold, von, 692 
Siegelman, 128 

Simon, 84, 91, 93, 256, 280, 700 
Simon-Hegar, 280, 284 
Simpson, Alexander, 274, 275 
Simpson, Sir James Y., 86, 361, 482, 546, 625 
Sims, Marion, -j^, 439, 450, 451, 732 
Skoldberg, 345 
Skrobanski, 225 
Smith, Greig, 545 
Smith, Heywood, 344 
Smyly, 693 
Snow-Beck, 362 
Spaeth, 124 
Spiegelberg, 694, 784 
Spohn, 767 
Steinthal, 723 
Sternberg, 120 
Stiegel, 568 
StilHng, 734 
Stimson, 172 
Stoltz, 442, 491 
Strassman, 53 



Stratz, 691 

Stroganoff, 116 

Sutton, J. Bland, 30, 50, 554, 584, 762, 780 

Taenzer, 113 

Tait, Lawson, 275, 276, 278, 366, 641, 815 

Talley, F. W., 90 

Tannen, 726 

Taylor, H. C, 133 

Tauffer, von, 706, 718 

Taussig, 763 

Teuffel, von, 707 

Thiersch, 727, 734 

Thomas, 346, 502, 635 

Thorn, 726 

Thornton, 786 

Thure-Brandt, 142 

Tilt, 197 

Toland, 360 

Torggler, 732, 735 

Tracy, S. E., 742 

Tratz, 581 

Trendelenburg, 73, 247 

Treves, 394 

Tuffier, 154, 169, 710 

Tuholske, 523 

Tyson, 508 

Ungara, 734 

Van De Warker, 700, 732 

Van Geison, 112 

Veit, 671, 707, 714, 744 

Vineberg, 487, 491 

Virchow, 361, 385, 612, 683, 685, 692, 751, 776 

Von Hacker, 164 

Vulliet, 96, 511, 734 

Walcher, 244, 246 

Waldeyer, 28, 670, 683 

Walsh, Joseph, 322 

Warder, 146 

Watkins, 443 

Watson, 259, 578, 663, 718 

Webster, 158, 479, 545 

Wecchi, 706 

Weigart, 113 

Weil, 752 

Welch, 665 

Wells, Spencer, 103 

Werder, X. O., 256, 714 

Wertheim, 120, 487, 678, 716, 717, 723, 725 

Westermark, 718 

White, 167, 502 

Widal, 349 

Wider, 52 

Wiggins, 446 

Williams, W. Roger, 665, 726 

Williams, J. Whitridge, 116, 751, 783 

Winckel, von, 207, 585, 598, 685, 691, 707, 724 

Winter, A., 36, 37, 669, 678, 689, 707, 724 

Wolff, 597, 781 

Wolffler, 721, 722 

Wyder, 28 

Wylie, W. GiU, 457, 477, 478, 488 

Zeiss, 118 

Zuckerkandl, 721, 724 

Zweifel, 116, 334, 646, 711, 723, 739, 760 



NDEX. 



HEAVY FACE TYPE INDICATES ILLUSTRATIONS. 



Abdominal examination, 76 

section, 76, 165 
Abortion, 60- 

incomplete, 528 

tubal, 523 
Abscess about appendix, 7 1 

collection in pelvis from appendix, 397 

from Bartholin's gland, 397 

intraperitoneal, 399 

tubo-ovarian, 377 

vulvar, 305 
Acarus scabiei, 118, 130, 311 
Acne, 311 

Adenocarcinoma of uterus, 665, 671 
Adenomatous cysts, 776 
Adenomyoma, 761 
Adenosarcoma, 750 
Adhesions, 62, 173 
Amenorrhea, 69, 137, 190, 301 

functional, 190 , 

pathologic, 190 

physiologic, 190 

operative, 190 

prognosis, 191 

treatment, 191 
Apostoli, 192 
Bier's, 192 
Amputation of the cervix, 232 
Anastomosis Ureteral, 261 
Anatomy and embryology of the genito- 

uninary organs of the woman, i 
Androgyna, 219 
Anemia, 65, 136 ,192 
Anesthesia, administration, 168 

agents employed in, 165 

artificial respiration in, 168 

contra-indications to, 168 

indications for. 165 

local, agents employed in, 168 
freezing, 168 
infiltration, 169 

scopolamin- morphine, 166 

spinal, 169 
Angiosarcoma, 750 
Angiotribe, 653, 658, 710 
Anodynes, 183 

Anteflexion of uterus, 454. See Uterus. 
Anteposition of uterus, 448 
Ante/ersion of uterus, 449. See Uterus. 
Antisepsis, 155 

of cervix and uterine cavity, 164 
Antispasmodics, 136 
Anus, anatomy of, 38 



Anus, columns of Morgagni, 35 

sinuses of Morgagni, 35 

Imperforate, Commimication between 
Rectimi and Vagina, 220 
Aponeurosis Excised, Showing Pyramid- 

alis Muscles, 173 
Apoplexy of the ovary, 30 

ov^arian, 507 
Apparatus, Northrup's, 167 

White's, 167 
Appendages, diplacement of, 505 

Prolapsus of Ovary and Tube behind 
Uterus, 505 

diagnosis, 506 

symptoms, 506 

treatment, 506 
Appendix vesiculosa, 31 
Applications, antiseptic, 144 

astringents, 145 

bUsters, 143 

caustic, 145 

counterirritants, 143 

croton oil, 143 

external, 143 

ice-bag, 143 

local, 144 

tinct. iodid, 143 

various agents, 144 
Applicator, Alimiinium Uterine, 145 
Arteriosclerosis, 193 
Artery, azygos vaginae, 40 

circular, of cervix, 40 

inferior hemorrhoidal, 40 

internal iliac, 40 

internal pudic, 41 

middle hemorrhoidal, 40 

of bulb, 42 

of clitoris, 42 

ovarian, 40 

puerperal, 40 

superficial perineal, 42 

transverse perineal, 42 

uterine, 40 

vaginal, 40 
Artificial heat, 183 
Ascaris lumbricoides, 118, 130 
Ascites, 595 
Asepsis, 155 
Aspiration, 103 
Aspirator, 104 
Atmocausis, 512 
Atresia, 210 

acquired, 210 

congenital, 210 
diagnosis, 211 



827 



828 



INDEX. 



Atresia, congenital, of cervix, 211 

of genital canal, 210 

of one horn of uterus, 204 

Atresia of Rudimentary Horn with 
an Accumulation of Menstrual 
Blood, 204 

of urethra and vagina, 204 

site of occurrence, 211 

symptoms, and signs of, 212 

treatment, 212 
Atropin, 104, 136, 168, 183, 186, 187, 403 
Auscultation, 78 



B 



Bacillus aerogenes capsulatus, 117, 128 

anthracis, 134 

coli communis, 123, 134, 320 

diphtheriae, 118, 128 

influenzae, 134 

leprae, 134 

mallei, 134 

of Doderlein, 116 

pestis, 134 

pyocyaneus, 117, 127 

smegma, 127 

tetani, 124 

tuberculosis, 123, 134, 322 

typhosus, 117, 123, 127, 134 
Bacteremia, 133 
Bacteria found in blood, 134 
Bacterial vaccines, 352 
Bacteriologic cultures, 116 

bacilli coli commimis, 123 

bacillus tuberculosis, 123 

gonococcus, 120 

staphylococcus pyogenes aureus, 118 

streptococcus pyogenes, 119 
Bacteriology of genital tract, 115 
Bartholinitis, 301, 308 

diagnosis, 309 

treatment, 310 
Basedow's disease, 190 
Baths, 138 

electric light, 140 

hot air, 140 

Nauheim, 138 

sea bathing, 140 

sheet bath and wet pack, 138 

sitz, 140 
Battery electric, Faradic Battery, 153 

Portable Galvanic Battery with Gal- 
vanometer, 152 
Bifidites, 201 
Binder, Scultetus, 816 
Bladder, 32 

anatomy, 32 

bas-fond, 33 

divisions of, 32 

duplication of, 221 

exploration of urethra, ureters and, 98 

exstrophy of, 221 

extirpation of, 579 

inflammation of, 98, 319 
acute, 319 

symptoms, 320 



Bladder, inflammation of, chronic, 319 
symptoms, 321 
injury to during operation, 658 
mucous membrane of, ;^^ 
position of, 32 
trigone of, 33 
tumors of, 571 
adenoma, 572 
classification, 571 
carcinoma, 572 
dermoid, 572 
myomata, 573 
diagnosis, 573 
symptoms, 573 
treatment, 574 

incision, abdominal, 575 
vaginal, 575 

operation, the, 575. See Operations 
papilloma, 572 
sarcoma, 572 
Blood, changes, 132 
culture, 134 
examination, 131 
Bloodletting, 143 
Bougies, Hegar's, 630 

in the ureters, 103 
Broad ligaments, 207, 764 
cysts of, 764 
with Torsion of its Pedicle, 765 
treatment of, 765 
fibroma of, 766 

confounded with epiplocele, 766 
with fatty hernia, 766 
with ovarian hernia, 766 
lipomata of, 765 
malignant growths of, 766 
parovarian varicocele, phleboliths, 765 
Buboes, 306 
Bulb of the vestibule, 9 
of the ovary, 43 



Cachexia, 686 
Calcuh, 100, 325 
Canal of Gartner, 31 
of Miiller, 203 
of Nuck, 3, II, 309, 559 
Cancer of uterus. See Carcinoma. 
Cannula, glass, 103, 163 
Carcinoma, 572 
classification, 665 

anatomic, 665 
clinical forms, 679 
dissemination of, 675 
histology, 670 
method of extension, 669 
of bladder and ureters, 572, 670 
of Fallopian tube, 763 
of ovary, 784 
of uterus, 664, 689 
of body, 67 1 

adenocarcinoma, 665, 671 
Adenocarcinoma of Body of the 

Uterus, 674 
Circumscribed Cancer of Body 
of Uterus, 679 



INDEX. 



829 



Diffuse Cancer of the Uterine 

Body, 680 
Adenocarcinoma of Uterine Body, 

680 
Incipient Adenocarcinoma of 
Uterine Mucous Membrane, 
681 
Entire Cavity Covered with Nod- 
ular Growths, 681 
Uterus Removed from an Un- 
married Woman Twenty-two 
Years of Age, 689 
Carcinoma of uteru,,, of body, adenocarci- 
noma, histology of, 673 
microscopic examination in diagno- 
sis, 674 
necrosis of, 673 
rarity of, 671 
of cervix, 666 
Cancerous Ulceration of Intracer- 

vical Canal, 676 
Cervical Wall Infiltrated while the 
Vaginal Portion is Largely De- 
stroyed, 677 
adenocarcinoma of, 66g 

of the Cervical Canal, 673 
frequency of, 671, 685 
Cervical Canal Destroyed by Prog- 
ress of Disease, 683 
methods of development, 669 
of extension, 660, 681 

cauliflower growth, 666, 681 
Cauliflower Growth Involving 
the Vaginal Part, 675 
clinical forms, 679 
cylindric cell, 665, 670, 679 
influence upon surrounding tissues, 
670 
Communication between Blad- 
der, Vagina and Rectum, 
682 
involvement of bladder and ureters, 
670, 687 
of other organs, 670 
process of extension, 670 
general, 664, 681 
of invasion of vagina, 677 

lymph-gland involvement, 678 
lymph-vessels principal route of 

extension, 678 
squamous cell, 665, 678 
Squamous-cell Epithelioma of 

the Uterus, 672 
development of, 666 
histolog}- of, 668 
structure of stroma, 668 
complications of, 690 
myoma, 691 
ovarian tumors, 690 
peri-uterine inflammation, 690 
pregnancy, 690 
diagnosis of, 692 
curet, 693 

differential from chorioepithelioma,694 
from chronic cervical catarrh with 
laceration, 694 



Carcinoma, diagnosis of, differential from 
necrosis of fibroid polypus, 694 
from papillary erosion, 694 
from partial retention of products 

of conception, 694 
from sarcoma, 694 
from syphilitic ulceration, 693 
laminaria tents, 693 
microscopic examination, test excision 
for, 693 
duration, 697 

of recovery, 725 
effect of, upon pregnancy and labor, 
691 
pregnancy and labor upon, 685 
etiology, 683 

Cohnheim's theor}-^, 683 
condition of life, 685 
heredity, 685 
Klebs' bacillus, 683 
origin from micro-organisms, 683 
Ribert's theor>', 683 
Ross' theor}', 684 
sex, 685 

sexual activity, 685 
Thiersch's theory, 683 
\^irchow's theory, 683 
Waldeyer's theory, 683 
glandular involvement, frequency of, 678 
physical signs, 689 
pregnancy complicating, 738 
prognosis, 697 
recurrence of, 698 
symptoms, 685 

amyloid degeneration of large glands, 

689 
cachexia, 686 

degeneration of kidney, 689 
dilated ureters, 687, 689 
distention of hemorrhoidal veins, 687 
and clinical course, emaciation, 688 
hemorrhage, 685 
hydronephrosis, 687 
lung embolism, 689 
metastasis, 688 
offensive discharge, 686 
pain, 686 
pleurisy, 689 
pneumonia, 689 
treatment, 698 

palliative, 699, 728 
caustics, 732 
cure ting, 729 

danger and injuries in, 729 

clry, 735 

local, 736 

parenchymatous injections, 734 

suture cureted surface, 735 

when disease far advanced, 735 

with fistula of rectum and bladder, 

735 
radical, 699, 702 

extirpation, total, 701 

by hysterectomy, abdominal, 712 
control of hemorrhage in, 7 15 
Freund's operation, 712 



830 



INDEX. 



Carcinoma, treatment, radical, exterpation 
by hysterectomy, in marked 
involvement of the cervix, 7 14 
modifications of, 713 
mortality in, 717 
by hysterectomy, vaginal, 704 
accidents of, 710 
by perineal method, 725 
Zuckerkandl's, 724 

Frommel's modification, 
724 
by sacral method, 718 
Skin Incision for Sacral 

Resection, 719 
Sacrum Resected ; Rectum 

Exposed, 720 
Rectum Pushed Aside ; 

Uterus Exposed, 721 
Patient from whom Uterus, 
Ovaries, Posterior Wall 
of Vagina, Perineum 
and Five Inches of 
the Rectum have been 
removed, 723 
clamp forceps in, 709, 760 
comparative advantages of ab- 
dominal and vaginal routes, 
717 
con tra-indi cations to, 717, 726 
control of bleeding vessels, 710 

by hot iron, 709 
deep vaginal incision in, 708 
difficulties in, 707 
disposition of ovaries and tubes, 

707 
injuries to bladder, 711 
injuries to one or both ureters, 

711 
injuries to rectum, 711, 761 
modifications of, 706 
mortality of, 725 
nonemployment of forceps or 

ligatures, 709 
Schuchardt's operation, 708 
treatment following operation. 

759 
possibilities of reinfection, 702 
partial operations, vaginal. 709 
amputation of cervix, with gal- 
vanocautery loop, 700 
Hegar's operation, 700 
Schrdder's operation, 700 
preliminary treatment, 704 
recurrence after operation, 712, 726 
diagnosis of, 727 

extension to parametrium, 727 
infection, 727 
lymph-gland, 708 
metastatic, 728 
lymph-glands source of redevelop- 
ment, 728 
summary, 739 

abdominal opertions, 740 
vaginal operations, 740 
Card index system, 114 
Caruncle, urethral, 197, 561 



Urethral Caruncle, 561 

Carunculae myrtiformes, 7, 197 
Catarrh, chronic cervical, 338 
Catgut, 242 

for ligatures, 158 

chromic, 159, 188, 244 
dry iodine, 159 
formalin, 159 
silverized, 159 
Catheter, double, 102, 164, 328 

Harris, Double Catheter for Obtain- 
ing Urine from Kidneys Separately, 
102 
Double-current Catheter, 328 
glass, 187, 315 
precautions in use of, 187 
Reflux Catheter, 320 
Self -retaining, 250 

Ureteral Catheters, Metal and Soft, 102 
Catheterization, 187, 314, 324 
microbes introduced by, 324 
of the ureters, loi, 322, 508 
Caustics, 145 

acid, carbolic, 145 
chromic, 145 
hydrochloric, 145 
nitrate of mercury, 145 
nitric, 145 
sulphuric, 145 
chlorid of zinc, 145 
creasote, 145 
liquid, 145 
silver nitrate, 146 
Cautery, galvano-, 709 
loop, 575 

Paquelin345, 575, 709, 714, 73i. 817 
thermo-, 411, 565, 640 
Celloidin, no 
CelluUtis, 387 
chronic, 386, 394 
diagnosis, 391 
Exudation in Broad Ligament from 
Pelvic Cellulitis, 389 
Exudation of Cellulitis over Rectum, 

390 
division of, 387 
etiology of, 387 

pelvic parametritis or periuterine phleg- 
mon, 386 
physical signs, 388 
prognosis, 392 
symptoms, 388 
treatment of, 393 
utero-sacral, 387 
Cervix, 21, 80, 701 

amputation of, 232, 233 
Double Flap Amputation of Cervix, 
232 
Sutures Introduced, 232 
Wound Closed, 233 
after-treatment, 234 
antisepsis of, and uterine cavity, 164 
areolar hyperplasia of, 340 
carcinoma of, 666 
chronic catarrh of, 338 
cystic degeneration of, 340 



INDEX. 



831 



Extensive Cystic Disease of the 
Cervix, 340 

Cervix, amputation of, double-flap, 233 
for areolar hyperplasia, 340 
for bilateral laceration of, 340 
for follicular erosion of, 340 
single flap, 233, 368 
erosion of, 339 
follicular, 340 
granular, 338 
simple, 339 
Simple Papillary Erosion of Cervix, 

339 
Simple Papillary Erosion with En- 
larged Follicles, 339 

hypertrophic elongation of, 424, 435 
incision of, 96, 631 

Lines of Incision for Contracted or 

Pinhole Os, 344 
Union of Vaginal and Cervical 
Mucous Membranes, 344 
complete, bilateral, 97 
inflammation of, 338 
causes, 341 
classification of, 338 
diagnosis,, 343 
physical signs, 342 
prognosis, 343 
s)miptoms, 342 
treatment, 343 

constitutional, 343 
electrical, 385 
local, 343 
surgical, 384 
lacerations of, 227, 252 

Slight Fissure of Cervix, 227 
Extensive Laceration of Cervix, 2 27 
Bilateral Laceration of Cervix, 228 
Slight StellatejLaceration of Cervix, 

228 
Extensive Stellate Laceration of 

Cervix, 228 
Laceration of Cervix with Hyper- 
trophy and Eversion of Cervical 
Mucous Membrane, 228 
complications of, 229 
diagnosis, 228 
symptoms, 227 
treatment, 229 
sarcoma of, 747 
septum of, 205 
Virgin Os and Cervix, 24 
Chancre, 569 
Chancroids, 125, 304, 569 

onganisms of, 125 
Chlorosis, 65, 67, 192 
Chlorotone, 311 
Chorioepithelioma malignum, 740 

Chorioepithelioma of the Uterus, 

741 
Chorioepithelioma Malignum, 742 
Histologic Section of Chorio-epi- 

thelioma, 742 
Uterus containing Mass of Chorio- 
epithelioma in Case of Dr. Her- 
man, Fig. 546. 



Microscopic Section of Chorio- 
epithelioma taken from above, 
745 

Chorioepithelioma, diagnosis, 743 
etiology, 743 
prognosis, 743 
symptoms, 743 
of fallopian tubes, 764 
Circulation, renal, 190 
Clamp forceps, 760 

Richelot's, 709 
Cleansing hands, 160 
CHmacteric, 53, 193, 509 

delayed in fibroid growths, 622 
discharge following, 72 
entire removal of the fallopian tubes to 
establish, 641 
Clitoris, 2, 46, 88, 313 
anatomy, 3, 4, 5) 
bifid, 215 
defects, 215 

Enlarged Clitoris, 216 
frenulum, 3 
prepuce, 3 
adherent, 216 

nervous symptoms produced, 216 
treatment, 216 
Coccyx, resection of, for artificial anus, 583 
Coition, 5, 7, 10, 53, 61, 65, 70, 223 
Colic, intestinal, 330 

uterine, 144 
Colostomy, 583, 724 
Colpitis, 332 

Colpocele, Anterior and Posterior, 427 
Colpocleisis, 251 

methods of procedure in, 251 
Colporrhaphy, anterior, resection of anterior 
vaginal wall for, 440 
Anterior Colporrhaphy. Anterior wall 

Removed, 440 
Wound Closed, 441 
Stolz's sutures in, 441 

Stolz's Purse-string Suture, 442 
Posterior, 442 
Comfort of patient, post-operative, 181 
Cummunications, abnormal, 222 
recto vaginal 221 
Communication of Rectum and Blad- 
der with the Vagina, 222 
Suprapubic opening of vagina and 

urethra, 222 
vagino-rectal, 221, 223 
Congenital Defect of Vagina. Com- 
munication with the Rectum 221 
vesico-vaginal, 221, 223 

Congenital Absence of the Urethra. 
Communication of Bladder with 
the Vagina, 221 
Conception, influence of myoma on, 617 
Conjunctiva, 189 
Condylomata of vulva, 126 
Connective tissue, distribution and relations, 

39 
pelvic, 39 
varieties, 39 
Copremia, 68 



832 



INDEX. 



Copulation, 49, 55, 193 
Corpus albicans, 30 
luteum, 30, 51, 53 
cysts of, 770 
of pregnancy, 30 
nigrans, 30 
Counter irritants, 143 
Culdesac, utero-rectal, 37 

vesico-uterine, 37 
Curet, 106 
Douche, 106 
Sharp Carets, 230 
Curetment, 351, 360, 368, 490, 630 
Cystadenoma, 803 
Cystaliga, 322 
Cystitis, 319 
acute, 319 

character of urine in, 321 
constitutional disturbances in, 321 
symptoms, 322 
chronic, 319 

coniitioa of urine in, 321 
constitutional conditions in, 312 
cystotomy for, 329 
diagnosis, 322 
hem ituri t in, 508 
symptoms of, 321 
etiology of, 319 

of goiorrhsal origin, 321, 323, 327 
path^lo^ic changes in, 320 
prophylaxis, 325 
prognosis, 325 
treatment of, 325 

calculi and foreign bodies, 326 
irrigation of bladder, 327 
medical, 326 
prophylactic, 325 
surgical, 329 
tubercular, 321 
Cystocele, 79, 267, 427, 439 
diagnosis, 431 

treatment, see Colporrhaphy Anterior. 
Watkin's Operation for Cystocele, 

443 
Situation of Uterus in Completion of 
Watkin's Operation, 443 

Cystoscope, electric, 99, 102 
Cystoscopes, 99 

Cystoscopic Investigation of the Blad- 
der, 1 01 

Cystoscopy, 10 1 
Cystotomy, 329 
Cysts, adenomatous, 776 
areolar, 776 

of Bartholin's gland, 309. Fig. 308 

treatment of, 310 
of broad ligament, 104, 764 
echinococcus, 764 
dermoid of bladder, 572 
of Fallopian tube, 761 
of ovary, 766, 780 
glandular, 771 

hydatid, of Morgagni, 31, 762, 766 
intrahgamentary, 773 
Nabothian, 458 
of vagina, 579 



Cysts, parovarian, 781 
residual, 768 



Dartoid, 2 

Deciduo-chorion cellulare, 740 

Depressor, Sim's, 92 

Descent or prolapsus of ovary, 506 
Desmoid tumor of abdominal walls, 604, 605 
Desmopycnosis, 478 
Destructive bladder mole, 740 

placental polyp, 664, 740 
Dextroflexion of the uterus, 421 
Diabetes mellitus, cause of vulvitis, 310 
Diagnosis, 64 

cause of error in, 65 

importance of correct, 65 

method of procedure in, 65 

senses employed in, 72 
Diaphragm, pelvic, 12, see Perineal Muscles 
Diarrhea, 65, 68 
Dilatation of the urethra, 98 

of the uterus, 92, 510 
bloodless, 92 
bougies, 96 
The Method of Dilatation with the 
Graduated Bougies, 97 
divulsion, 92 
gauze packing, 96 
gradual, 92, 90 
incision, 92, 96 
bilateral, 97 
rupture by, 96 
tents, 92 
Dilators, Baer's, 95 

Ellinger's, 95 

Goodell's Modification, 95 

Hegar's, 630 

Pratt's, 96, 368 

Sims' Glass Dilator, 210 
Diplococcus intracellularis meningitis, 134 

of Siegelman, 128 
Discharge, genital, 71 

catarrhal, 71 

cervical, 72 

effect of age upon, 72 

origin of, 71 

simulating abscess, 7 1 

sources of purulent, 71 

vaginal, 72 
Dislocations of uterus, 448, see Uterus. 
Displacements of pelvic organs, 417 

of the appendages, 505 

of the ovary, 207 

of the uterus, 417. See Uterus. 
Divulsion, uterine, 95 
Douche, 142, 365 

alkaline, 143 

antiseptic, 142 

astringent, 142 

hot, 358, 360 

normal salt, 214 

rectal, 143 

vaginal, 192, 229, 489 

vesical, 143 
Douglas, pouch of, 37 



INDEX. 



833 



Drain, gauze, 177 

Gauze Drain Covered with Rubber 
Tissue, 177 

Chamber's Drain, 148 
Introducer for Chamber's Drain, 
149 

Mikulicz Drain, 177 

Wylie Drain, 148 
Drainage, 176 

management of, 176 

objections to, 176 

postural, 178 

Uterine Syringe for Cleansing Drainage- 
tube, 175 

tube, 175 
Dressing of wound, 180 
Dressings, 160 
Dysmenorrhea, 69, 193 

diagnosis, 193 

etiology, 194 

exfoliative, 194 

membranous, 194, 358 

symptoms, 193 

treatment, 194 
Dyspareunia, 70, 196, 205 



Ectopia of bladder, 221 
Eczema of vulva, 311 
Edema, 564 

of labium, 308 

of vulva, 564 
Electricity, 150 

Apostoli's method; 150 

battery for, 152 

contra-indi cations, 151 

electrodes, 154 

faradic, 150 

Finsen light, 153 

forms of, 150 

Franklinic, 150 

galvanic, 150 

Routgenic, 151 

sinusoidal, 151 
Electrocautery and light, 153 
Electrode, Bipolar Uterine, 154 

Intra-uterine Electrode with Movable 
Insulating Cover, 152 

Vaginal Electrodes of Different Sizes, 

153 
Vaginal Electrode, Bipolar, 154 

Elephantiasis of vulva, 564 

Elytritis, 332 

Elytrotomy, 547 

Embryo, Human, at End of Thirty-five 

Days, 2 
Embr}'ology and anatomy of the genito-urin- 

a.ry organs of the woman, i 
Enchondroma, 568 
Endocervicitis, 338, 341 

Chronic Endocervicitis, 341 

symptoms, 342 
Endometritis, 137, 193, 228, 254, ss7, 342, 
355, 3^3, 368 

acute, 338 

chronic, 355 

53 



Polyoid Masses Associated with 
Chronic Endometritis, 357 

Endometritis, diagnosis, 349, 358 
discharge associated with, 356 
villous degeneration, 357 
exfoliative, 357 
fungosa, 357 
gonorrheal, 357 
hemorrhagic, 363 
Hypertrophic Glandular, showing in- 
crease in size and number of glands, 

355 
Hypertrophic Glandular Endometritis. 
Vesical Section through the Mucus 
Membrane, 356 

influence upon conception, 358 
Interstitial Endometritis, 354 
membranous, 357, 360 
pathologic alterations, 359 
prognosis, 350 
senile, 64, 357, 361, 756 
symptoms, 357 
treatment, 359 
caustics in, 359 
cure ting, 358 

contra -indications for, 358 
dilatation with laminaria tents, 360 
drainage in, 359 
hot vaginal douche, 360 
intrauterine injections, 359, 361 
irrigation with antiseptics, 359 
prophylactic, 357 
repair lacerations, 359 
scarification, 360 
tampons, 360 
varieties and source. 347 
virginal, 357 
Endometrium, 23 

Section of Normal Endometrium, 23 
tuberculosis of, 758 
Endoscope, Skene's, 98, 317 
Endothelioma of ovary, 784 

uteri, 746 
Enterocele, vaginal, 434 
Enterocele through the Posterior Vag- 
inal Fornix, 435 
Enteroptosis, how avoided, 491 
Epilepsy, 363 
Epiplocele, 766 
Episiostenosis, 251 
Epispadias, 220 
treatment, 221 
Epithelial pearls, 668 
Epithelioma of uterus, 668 
of vagina, 582 
Vagino-uterine Prolapse Complicated 
by Proliferating Epithelioma, 436 
of vulva, 568 
Er}^sipelas of the vulva, 190, 304 
Etiolog}^, 55 

hereditary and congenital, 56 
hygienic, 58 
incident to age, 63 
infective, 62 
sexual, 59 
traumatic, 61 



834 



INDEX. 



Evacuator, Kelly's, 93 
Examination, 72 

abdominal preliminaries, 75 
aspiration, 104 
auscultation, 78 
exploratory incision, 104 

puncture, 108 
inspection, 76 
palpation, 77 

diflficulties in, 78 
percussion, 78 
preliminaries, 75 
Proper Position of Fingers for 

Examination, 80 
tapping, 103 
instrumental, 85 
probes, 86 
Sims', 86 
wlia,lebone, 86 
sound, 86 
speculum, 88 
tenaculum, 89 

double, 92 
tubular, 88 

univalve or duck-bill, 90 
val\^ular, 89 
microscopic, 105, 108 
collection of tissue, 105 
disposition of tissue, 108 
test curetment, 106 
test excision, 105 
pelvic, 79 

bimanual procedure, 80, 82 
difficulties of, 82 
digital, 79 
precautions in, 85 
in virgins, 83 
inspection, 79 
position of patient, 72 
preliminaries, 75 
preparation, 79 
procedure, 79 
rectal touch, St, 

Recto-abdominal Palpation, 83 
recto-abdominal, 83 
recto-vaginal, 83 
recto-vaginal-abdominal, S^ 
recto-vesical, 83 
Simon's method, 84 
simple touch, 79 
urethral, 98 
vesical, 98 
Exercise, 193 
Exploration of urethra, bladder and ureters, 

98 
Exstrophy of bladder, 221 
External violence, 223 



Facies, ovariana, 64 

uterina, 67 
Failure in microscopic examination, 105 
Fallopian tubes, 20, 121, 364, 485 
absent or rudimentary, 206 
coats of, 25 
mucosa, 26 



Fallopian tubes, coats of, muscular, 26 
serous, 26 
convoluted, 375 
description of, 24 
divisions of, 24 
ampulla tubae, 24 
fimbriated extremity, 25, 206 
infundibular tubas, 24 
isthmus tubae, 24 

Section of Fallopian Tube 

through the Isthmus, 25 
Section of the Fallopian Tube 
through the Ampulla near the 
Isthmus, Showing Extensive 
Folding of the Mucous Mem- 
brane, 27 
ostium abdominale tubse, 25 
ostium uterini tubse, 24 
inflammation of, 370. See Salpingitis 
length of, 24 
openings of, 20, 25 
resection of, 384 
tumors of, benign, 761 
cysts of small size, 761 
dermoid, 761 
enchondromata, 761 
fibrocyst, 761 
fibroma or myoma, 761 
papillomata, 762 
hydropic, 762 
simple cystic, 762 
polypus, 762 
malignant, 763 
^ carcinoma, 763 

chorioephithelioma, malign um, 764 
. sarcoma, 763 
Faradic current, 152 
Farre, white line of, 28 
Fascia, anal, 11 
deep, 10 

layer of superficial, 10 
obturator, 11 
pelvic, II, 39 
perineal, 10 
pyriform, 11 

relation to pelvic structures, 12 
superficial, 10 
triangular ligament, 1 1 
vesico-rectal, 11 
Fecundation, 49, 55, 520 

union of spermatozoid and ovum, 55, 520 
Feeding, rectal, 183 
Fibrocyst, 761 
Fibroid growths in the uterus a cause of 

anteversion, 450 
Fibroma of the broad ligament, 766 
and myxoma, 567 
submucous, 587 
of tubes, 761 
Fibromyoma of cervix, 595 
of ovary, 782 
of uterus, 584 
Fibromyomata, 584 
Fibrosarcoma, 750, 755, 759 
Fimbria ovarica, 25 
Finsen light, 153 



INDEX. 



83s 



Fissure, anal, 68 
vesico-urethral, 316 

appearance of, 317 

site of, 316 
Fistula, 62, 68 
Fistulse, 236, 309 

Scheme Showing Various Fistulae, 

237 
Colpocleisis, 251 

Closure of Fistula after its Exposure 
by Incision through Anterior 
Vaginal Fornix, 252 
causes of, 236 
cervical, 254 
cervico-vaginal, 236, 263 
fecal, 236 

ano-vulvar, 236, 262 

treatment, preliminary and after 
240, 262 
entero-vaginal, 236, 263 
recto-vaginal, 124, 225, 236, 252, 261 
Imperforate Anus, Communica- 
tion between Rectum and 
Vagina, 220 
Sagittal Incision for Recto- 
vaginal Fistula, 262 
Lauenstein Suture in Recto- 
vaginal Fistula through Rectal 
Wall, 262 
Rectal Wall Closed by Trans- 
verse Line of Sutures ; Vaginal, 
by Vertical Line of Sutures, 
263 
Recto-vaginal Fistula Closed in 
Operation of Perineorrhaphy, 
264 
genito-urinary, 236 

uretero-vaginal, 236, 254, 258 
urethro-vaginal, 236, 252 
urinary, 236 

utero-ureterine, 236, 253, 255 
vesico-uterine, 236, 252 

Vesico-uterine Fistula, 250 
vesico-utero- vaginal, 236, 254 
vesico-vaginal, 236, 241, 257 
Large Vesico-vaginal Fistula 
with Prolapse of the Anterior 
Vesical Wall through the 
Opening, 238 
Denudation of the Edges of the 

Fistula, 239 
Sutures Introduced, 240 
Wound Closed, 241 
Method of Suturing to Decrease 
the Tension upon the Sutures, 
242 
Showing Continuation of Sutures 
to Close Fistula with Incisions 
to Decrease Tension with 
suture Introduced on Left Side 
to Close the Secondary Open- 
ing, 243 
Wound Closed, 243 
diagnosis, 237 
etiology, 236 
prognosis, 239 



Fistulce, symptoms, 236 
treatment, 239 

accidents and results of, 260 
calculi and concretions, 261 
hemorrhage, primary, after, 260 

secondary, after-, 260 
inclusion of ureters, 261 
peritonitis, 261 
after-, 250 

by cauterization, 239, 263 
by colpocleisis, 251 

combined with recto-vaginal fistula, 2 51 
objections to, 251 
by denudation and suture, 241, 263 
by episiostenosis, 251 
by flap-formation, 247 

advantages of, 248 
by flap-splitting, 243 
by hysterocleisis, 253 
by hysterostenosi^s, 253 
preliminary, 240 
uretero-vaginal-uretero-cervical, 255 
treatment of, 256 

by anastomosis through the abdomen 
261 
through the vagina, 258 
by introduction of the ureter into 

rectum or colon, 259 
by Ugation of the ureter, 259 
by nephrectomy, 260 
urethro-vaginal, 252 
Operation for Uretero-vaginal 

Fistula, 258 
Vaginal Implantation of the Ureter 

into the Bladder, 259 
Abdominal Transplantation of Ureter 
for Uterero-vaginal Fistula, 260 
vesico-uterine, 250 
Fistula Closed into Vagina Uterine 
Opening Remains, Which will 
Close Itself, 253 
Closure of Fistula within Cervical 
Canal after Splitting Cervix, 254 
vesico-utero vaginal, 254 
Anterior Lip of Cervix Utilized to 

Close the Fistula, 256 
Vesico-uterovaginal Fistula in which 
the Posterior Lip of the Uterus is 
Utilized to close the Opening, 256 
vesico-vaginal, 718 
Vesical Wall Loosened and Sutured. 
Vaginal Wall Sutured in Opposite 
Direction, 257 
Corson's method of flap-splitting, 245 
Introduction of Vaginal Sutures, 249 
Section Showing Projections upon 

Vesical Surface, 250 
flap-formation, 247, 248 
Flap-formation as suggested by 

Ferguson, 247 
Flap Turned in and Vesical Opening 
Closed, 248 
flap-splitting, 243 
Fistula Preparatory to Splitting 
into Vesical and Vaginal Flaps, 
244 



8s6 



INDEX. 



Demonstration of Flap-splitting, 

244 
Suture Introduced into Vesical 

Flap, 245 
Suture Tied in Vesical Flap Intro- 
duced into Vagina, 245 
Wound Closed, 245 
Sutures Introduced to Close Vesi- 
cal Surface, as Suggested by 
Walcher, 246 
FistuLie, vesico-vagiiial, flap-transplantation, 

246, 262 
Flap operations, 244, 271 
Flexion, anterior of uterus, 488 

lateral, 488 
Fluids and secretions, collection of, 128 
Forceps, Clamp for Securing the Broad 
Ligament, 410 
Dissecting, 174 

Mouse-tooth, for Cotton Pledgets, 93 
Pressure, 174 
Tenaculum, Double, 93 
Tube, for Cotton Pledgets, 176 
Uterine-Dressing, 94 
Fornix, anterior vaginal, 85 

posterior vaginal, 85 
Fossa navicularis, 8 
Fourchet, 3, 8 
Franklinism, 150 
Furuncle, 310 

G 

Galvanic current, 150 
Galvano-cautery, 709 
knife, 700 
loop, 700 
Gangrene of the vulva, 308 
Gartner, canal of, 31 
Gauze, 163 
acetanilid, 164 
borated, 164 
carbolized, 164 
drain, 177, 185 ■ 
formalized, 164 
iodororm, 163, 630, 712 
pack, 197, 214, 369, 705, 712, 729 
Pads, 157 
salicylated, 164 
sterilized, 231 
sublimate, 164 
tampons, 760 
Wick in Drain, 176 
Genital tract, atresia of, 210 

Degrees of Division of the Genital 

Tract, 201 
Hemorrhage or bleeding, 509. See Hemor- 
rhage, 
organs, 2 

development of, i 
functions of, 49 

copulation, 49, 55, 195 
fecundation, 49, 55, 520 
injuries of, 223 
menstruation, 50 
nubility, 49 
parturition, 49, 223, 226 



Genital organs, functions of, puberty, 49, 83 
malformations, 63, 200 

classification, 200 
tract, bacteriology of, 115 

parasites of, 116 
tumors, 556. See under Tumors. 
Genitalia, division of, 2 
external, 2 
External Genital Organs of Madam 
LeFort, 218 
internal, 2, 14 

Outline of Internal Organs of Madam 
LeFort, 218 
lymphatics of, 45 

Progress of Development of the Gen- 
italia, 3 
Geni to-urinary fistula, 236 

hemorrhage, 506. See Hemorrhage, 
organs, development of, i 
function of, 49 
physiology of, 14 
tract, inflammation of the entire, 298 
Germinal epitheHum, 28 
spot, 29 
vesicle, 29 
Gestation, 49 
ectopic, 520 
causes of, 520 
course and progress of, 523 
abortion, tubal, 525 

Tubal Abortion, 523 
mesometric or intraligamentary, 

, . 525 

moles, tubal, 525 
rupture, complete, 528 
Complete Rupture of a Tubal 

Sac, 528 
incomplete, 525 
Incomplete Rupture of Gestation 

Sac, 529 
An Ectopic Gestation Sac Sim- 
ulating an Ovarian Cyst, 529 
primary, 526 
secondary, 531 
. _ treatment, 533 
diagnosis, 538 

continued growth after rupture, 541 
peritonitis, 542 
preceeding rupture, 538 
rupture, 538 
Ectopic Sac Ruptured Showing 
Fetus, 540 
secondary rupture, 541 
suppuration, 542 
differential, 542 

from accumulation of feces in rectum, 

544 
from intrahgamentary tumors, 544 
from ovarian tumors, 544 
from pregnancy in bicornate uterus, 

543 
from retroflexed gravid uterus, 543 
from spurious pregnancy, 544 
from tubal rupture, 544 
from uterine pregnancy, 543 
from uterine tumors, 544 



INDEX. 



837 



Gestation, lithopedion in, 534 
macerated fetus, 534 
mummification of fetus, 533 

Calcified Ectopic Gestation Sac, 

534 
Photograph of the Skeleton Dis- 
sected and Arranged from the 
Original Specimen Seen in above, 

535 
Sac, Large Ectopic Gestation, 543 

symptoms, 536 
treatment, 546 
electricity, 546 
elytrotomy, 546 

evacuation of liquor amnii, 546 
operative, 548 
varieties, 521 
Gland, Bartholin's, 9, 129 
Duverney's 308 
obturator of Guerin, 45 
Glands, hypogastric or iliac, 45 
inguinal, 45 
lumbar, 45 
lymphatic, 45 
of Naboth, 24, 61 
sacral, 45 
utricular, 316 
Gloves, rubber, 161 

Gonococcus, of Neiser, 112, 120, 134, 310, 
318, 323, 335 
examination for, 121 
Gonorrhea, 122, 350 
Graafian follicles, 2;9 

corpus luteum of, 30 
nucleus of, 29 
Growths, urethral, 561 
Gynandria, 219 
Gyroma, 783 

H 

Hematoma, 180 
Hematometra, 212, 733 
Hematosalpinx, 212, 372, 733 
Hemoglobin, 135 
Hemorrhage, 69, 98, 317 
from urinary tract, 99 
genital, 509 
causes, 509 
diagnosis, 509 
treatment, 511 
geni to-urinary, 506 

site and varieties, 507 
hematocele, 512 

extraperitoneal, 516 

Extraperitoneal Hematoma, 
517 
diagnosis, 517 
prognosis, 518 
symptoms, 516 
treatment, 518 
intraperitoneal, 507, 515 

Intraperitoneal Hemorrhage, 

516 

diagnosis, 517 

prognosis, 518 

symptoms, 515 



Hemorrhage, hematocele, intraperitoneal, 
treatment, 518 
incision, abdominal, 519 
vaginal, 519 

Hgation of bleeding-vessels, 98, 519 
hematocolpometra, 212, 214 
hematocolpometrasalpinx, 21, 507 
hematocolpos, 212, 213, 507 
hematoma, 507, 517 
ov^arian, 30, 507 
vaginal or thrombus, 507, 513 
diagnosis, 514 
treatment, 514 
vulvar, 512 
hematometra, 212, 213, 507 
hematosalpinx, 399. See Pelvic Peri- 

tionitis. 
hematuria, 507 
causes, 507 

symptoms and diagnosis, 507 
treatment, 508 
internal, 184 
menorrhagia, 507 
metrorrhagia, 507 
periuterine, 514 
causes, 515 
symptoms, 515 
primary, after fistula, 260 
secondary, after fistula, 260 
site and varieties, 507 
treatment, 508 

urinary, 507. See Hematuria, 
vulvo-vaginal thrombus, 514 
Hemorrhoids, 68, 79, 83, 311 
Hermaphroditism, 58, 217 
Apparent Hermaphroditism, 217 
Angrogyna, 219 
epispadias, 220 
treatment, 221 
g}-nandria, 219 
hypospadias, 220 
pseudo-hermaphorditism, 58, 218 
divisions of, 219 
Hernia, 558 
Anterior Labial or Inguinal Hernia, 559 
fatty, 766 
ovarian, 766 

Posterior Labial Hernia, 560 
Herpes of the vulva, 304, 306 
History, method of securing, 65 
Hottentot apron, 4 
Houston valve of, 36 
Hydrocele, 559 
Hydrometra, 662 
Hydrops folliculorum, 769 

tubse profluens, 71, 373, 771 
Hydrorrhea, 363 

Hydrosalpinx, 399. See Pelvic Peritonitis. 
Hymen, 6, 9 
Annular, 6 
atresia of 217 
Biseptus, 8 

congenital absence of, 217 
Crescentic, 6 
Cribriformis, 8 
defects of, 216 



838 



INDEX. 



Hymen, falciform, 6 

imperf orations of, 63, 212 
Infundibularis, 7 
labia-like, 6 
Laceration of, 9, 217 
linguaformis, 6 
rupture of, 7 
shape of, 6 
supernumerary, 217 
Hyperemia of the urethra, 314 
Hyperplasia, 193 

Hypodermoclysis of normal salt solution for 
hemorrhage, 184 
for peritonitis, 185 
Hypospadias, 219 

Hysterectomy, abdominal, 135, 164, 656 
accidents during, 658 
hemorrhage, 658 
injuries of viscera, 659 
injuries of intestines, 660 
injuries of ureter, 659 
causes of death after, 661 
pan-, 657 
partial, 645 
vaginal, 640 
Ligation of the Broad Ligament in 

Vaginal Hysterectomy, 413 
by morcellement, 637 
Closure of Vaginal Wound by Sutures, 

416 
description of operation, 640 
Introduction of Gauze after Re- 
moval of the Uterus, 415 
mortaUty, 725 

Landau's Method of Delivering the 
Uterus after its Complete Median 
Section, 417 
Hysteria, 65 

Hysterostenosis, or hysteroclesis, 253, 255 
Hystero trachelorrhaphy, 231 

I 
Ice-bag, 393 
Ileus, 185, 760 

Immunity, natural agents of, 117, 298 
Incision, abdominal, for tumors of the blad- 
der, 575 
crescent, 172 
Crescent Incision Exposing Aponeu- 
rosis, 173 
Aponeurosis Excised, Showing Pry- 
amidalis Muscles, 173 
exploratory, 104 
length, of, 172 
vaginal, 185 

for tumors of the bladder, 575 
Infection, 155, 298, 395 
gonorrheal, 299, 300, 521 
streptococcic, 300 
wound, 185 
Inflammation, 298 
acute, 299 
causes, 299 
symptoms, 300 
characteristics of, 300 
chronic, 299 



Inflammation, classification of, 301, 383 
diffuse, 299 
exacerbations, 300 
follicular, of urethra, 315 
of bladder, 99, 319. See Cystitis. 
of cervix and body of uterus, 357 
of entire geni to-urinary tract, 298 
of Fallopian tube, 370. See Salpingitis, 
of ovary, 378. See Oophoritis, 
of ureter, 99 

of urethra, 300. See Urethritis, 
of vagina. See Vaginitis, 
of vulva, 302. See Vulvulitis. 
pelvic, 385 

varieties of, 386 

peritonitis parametritis, perisalpin- 
gitis and perioophoritis. See Pelvic 
Peritonitis, 
periuterine, 193. 359 
Injections, bovinin, 183 
carbolic acid, 164, 311 
deodorizing, 164 
dioxide of hydrogen, 164 
disinfectant, 164 
formalin, 164 
intrauterine, 164 

intravenous of corrosive sublimate, 353 
formahn, 353 

of normal salt solution, 183, 352 
of quinin, hydrochlorid of, 353 
milk, 311 

sublimate, 164, 304 
Inspection, 76. Fig. 52, page 78 
Instruments for examination and operation, 

156 
Insufflator, Straight Stem, 145 

Intussusception, 186 

Inversion of the uterus, 492. See Uterus. 
Iodoform pencils, 145 
Irrigating tubes, 163 
Irrigation, 183 
vaginal, 188 

K 

Kidney, floating, 610 
Knives, for Denudation, 224 

Kobelt's tubules, 782 
Koch's bacillus, 123 
Kraurosis, vulvae, 312 

causes of, 312 

diagnosis, 313 

division of, 312 

prognosis, 313 

symptoms, 312 

treatment, 313 



Labia, majora, 2, 58 

anatomy of, 2, 3 
minora, 2, 3, 6, 58, 79, 313, 324 

anatomy of, 3, 4 
Lacerations of cervix, 61, 227 

complications of, 229 

diagnosis, 228 

symptoms, 227 

treatment, 229 



INDEX. 



839 



Laceration of cer\'ix, treatment, after-, 234 
amputation of the cervix, 202, 233 
trachelorrhaphy, 231, 264 
of pelvic floor, 61, 264 
causes, 265 
degree or extent, 266 
operation for complete, 276 
choice of operation, 296 
for incomplete, 279 
after-treatment, 279 
intermediate operation, 268, 

270 
piimar}' operation, 268 
advantages of, 270, 274 
contra -indications, 270 
secondary operation, 270 
results, 267 
of the vagina, 234 
Laceration prolonged to avoid conception, 

53 
Lateral flexion of uterus, 488 
Latero-position of uterus, 448 
Lateral version of uterus, 453 
Leukocytes, 133, 135 

malignant, 133 
Leukorrhea, 6, 65, 70, 332, 363, 364 
Lleberkiihn's crypts, 35 

follicles, 36 
Ligament, broad, 21, 37, 46, 207 

infundibulo-pehdc, 37 

interureteric, 2;^ 

ischioperineal, 11 

of rectum, 12 

of uterus, 48 

ovarian, 26 

Poupart's, II, 39, 355, 474 

pubo-vesical, 12 

round, or broad, 11, ^y, 47 
defects of, 207 

triangular, 10 

uterosacral, 48 

uterovesical, 48 
Ligature and suture material, 158 
Linea alba, 170 

ani rectaHs, 35 

nigara, 76 

striata, 76 
Liomyomata, 587 

Liomyoma of the Uterus, 587 
Lipoma, 568 
Lipoma ta, 765 
Lithopedion, 534 
Lupus, 190 

Lymphangiectasis, 761 
Lymphatic system, 45, 332 

glands, 45 

hypogastric, 45 
inguinal, 45 
lumbar, 45 
The Lumbo-iliac Lymphatics and 
Glands, 46 
of Guerin, 45 
peMc, 45 
sacral, 45 

vessels, 47 
Lymphosarcoma, 750 



Malarial plasmodia, 134, 349 
Malformations, classification and definition 
of, 200 
bifidities, 201 
degrees of division, 201 
Degrees of Division of the Genital 

Tract, 201 
Uterus Bicornis, 201 
Uterus Bicornis Unicollis, 202 
Uterus Bifidus, 202 
Uterus Didelphys, 203 
Uterus Unicornis, 203 
Atresia of Rudimentary Horn with an 
Accumulation of Menstrual Blood, 
204 
Uterus Bipartitus or Duplex, 205 
Uterus Biseptus, 205 
treatment of, 205 
Malignancy, proportion of, in ovarian 

tumors, 664 
Mahgnant chorion, 740 
disease, 104 
neoplasms, 582 
Mammar}' gland, 137, 189 
Massage, 136 
general, 141 
pelvic, 141, 438, 451, 457 

Position of the Fingers in Pelvic 
Massage, 141 
contra-indications, 141 
difficiilties of, 141 
indications for, 141 
Mastmrbation, 216, 219, 305, 310, 330, 363 
Meatus urethrae externus, 6 
Membrana granulosa, 29, 48 
Membranous dysmenorrhea, 194 
Menopause, 53, 310, S33 

chemic changes in blood and tissues, 54 
duration, 54 
early, 54 

hemorrhage during, 54 
premature, 54 
retarded or delayed, 54 
time of occurrence, 53 
vasomotor disturbance of, 54 
Menorrhagia, 69, 301, s6s, 368, 393, 599 
etiology, 193 
symptoms, 192 

symptom of endometritis, 357 
treatment, 193 
Menses, 50, 65 
Menstruation, 30, 188, 193, 310, 342 

after complete removal of ovarian stroma, 

53 
amount of blood lost, 51 
and ovulation, 50 
Changes of Uterine Mucous Membrane 

During Menstruation, 52 
disturbance of, 52, 189 

of mental equilibrium in, 51, 189 
duration of, 51 
during pregnancy, 53 
intervals of, 51 
local pain, 188 



840 



INDEX. 



Menstruation, purpose of, 51 
symptoms of, 51, 188 
symptoms of in remote organs, 189 
synonyms of, 50 
time of occurrence of, 51 
vicarious, 188 
Metritis, 63, 66, 301, 320, 337, 350, 449 
and endometritis, acute, 193, 346 
chronic, 361 

associated with cancer, 362 
course and prognosis, 365 
diagnosis and physical signs, 364 
differential, 361, 364 
from cancer, 362, 364 
from pregnancy, 364 
from rectal disease, 465 
from small fibroids, 365 
divisions of, 361 
etiology, 362 
abortions, 362 
cellulitis, 362 
congestion, 362 
contusions from pessary, 363 
inflammation, 362 
lacreations of the cervix, 362 
micro-organisms, 347 
retention of placenta, 362 
subinvolution, 362 
symptoms, 363 
leukorrhea, 364 
menstrual disturbances, 363 
sterihty, 364 
synonyms of, 361 
treatment, 365 

abdominal binder, 365 
amputation of the cervix, 368 
counterirritants, 365 
dilatation and curetment, 368 
Uterus Dilated with Graduated Bou- 
gies, 367 
Uterine Cavity Packed with Gauze 
after Dilatation, 368 
douches, 365 
ergot, 365 
exercise, 365 
hip baths, ;^66 
hysterectomy, 369 
medicated baths and waters, 365 
pessary, 365 
preventive, 365 
puncturing and scarifying the cervix, 

367 
rest, 365 

Schroder's operation, 368 
tampons, 367 
diagnosis, 364 
prognosis, 365 
sapremic, 347 
septicemic, 347 
symptoms of sapremia, 347 
of septicemia, 348 
Metrorrhagia, 69, 192, 301, 599 
Micro-organisms, 59, 62, 116, 121, 320, 323 
as a cause of inflammation of the genito- 
urinary tract, 299 
Microscope, 105 



Microscopic examination of a fresh specimen 

108 
Microtome freezing, 109 
Micturition, frequent, 68 
Miscarriage, 65 

Moles and cysts of the uterus, 663 
Mons veneris, 2, 88 
Morcellement, 637 
Morgagni, columns of, 35 
hydatid of, 31, 761, 766, 768 
sinuses of, 35 
Mucometra,* 662 
Miiller, canal of, 203 

Duct of, I, 3, 57, 298, 522, 533, 558, 579 
693, 769 
Coalescence of Miiller's duct, 3 
Muscles, 8 

bulbo-cavernosus, 8 
coccygeus, 12 
erector chtoridis, 8 
ischio-coccygeus, 12 
levator ani, 8, 12 
obturator coccygeus, 12 
obturator intemus, 12 
of Guthrie, 31 
pelvic diaphragm, 12 
perforations of, 12 
pubo-coccygeus, 12 
transversus perinei, 12 
Myoma of the bladder, 573 
Myomata, uterine, 594 
adhesions, 616 
complications, 615 

Myoma Uteri with Large Intra- 

ligamentary Fibromata, 610 
Uterus Containing Large Fi- 
broid Tumor and Three 
Months' Fetus, 6^4^ 
ascites, 615 
A Myoma which from the Asso- 
ciated Ascites Had Been Mis- 
taken for Pregnancy, 617 
Tumor Shown after Removal, 
618 
disease of the tubes, 616 
Myoma Uteri Complicated by 
Py ©salpinx, 616 
inflammation, 615 
ovarian hematoma, 617 
Uterus Containing Several 
Fibroid Tumors Complicated 
by a Large Tubo-ovarian Cyst, 
616 
pregnancy, 617 

Myoma Complicated by Preg- 
nancy, 619 
course and prognosis, 620 
degeneration of, 586, 610 

Myoma of the Body and Cancer 

of the Cervix, 613 
Uterus Incised, Displaying Nu- 
merous Fibr ©myomatous 
Growths and Incipient Cancer 
of the Cervix, 614 
adenomyomatous, 587 
calcification, 586, 612 



INDEX. 



841 



Myomata, degeneration of, colloid myxo- 
matous, 586, 612 
edema (hematoma) 587, 611 
fibrocystic tumors, 586, 612 
Fibrocystic Tumor of the Uterus, 
611 
inflammation, suppuration and gan- 
grene, 590, 595, 613 
from compression, 595 
■ from injury, 595 
from septic infection, 595 
lymphangiectatic, 587 
malignant, 614 
sarcomatous, 587 
telangiectatic, 587 
diagnosis, 602 

Intraligamentary Myoma, 603 
consistence of tumor an important 

factor, 602 
difl'erential, 604 
from abortion, 607 
from carcinoma, 608 
from desmoid tumor of abdominal 
walls, 604 
Large Desmoid Tumor of Ab- 
dominal "Wall Weighing, 
Upon Removal, Nineteen and 
One-half Pounds, 606 
Histologic Section of Desmoid 
Tumor, 607 
from displaced ovaries, 609 
from displaced uteri, 609 
from extrauterine pregnancy, 604 
from floating kidney, 610 
from glandular ovarian cyst, 609 
from inversion, 608 
from pelvic infiltration, 609 
from pregnancy, 604 
from sactosalpinx, 609 
from sarcoma, 608 
from subinvolution with endo- 
metritis, 608 
etiplog}' of, 597 

influence of age, 597 
of heredity, 597 
of irritation, 597 
of sexual irritation, 597 
influence of on conception, 617 
on labor, 619 
on pregnancy, 619 
pregnancy on myoma, 618 
microscopic appearance of, 585 
pathologic anatomy of, 585 
consistency, 585 
mixed growths, 615 
carcinoma. 615 
en chondroma, 615 
myocarcinoma, 615 
myochondroma, 615 
myosarcoma, 615 
osteoma, 615 
sarcoma, 615 
structure of, 586 
symptoms of, 598 

abdominal cramps, 598 
anemia, 599 



Myomata, symptoms of, cachexia, 602 
constipation, 602 
fissure of anus, 599, 601 
frequent micturition, 599 
hemorrhage, 599 
hemorrhoids, 600 
hydronephrosis, 601 
itching and burning of anus, 599 
leukorrhea, 600 

metrorrhagia from rupture of veins,6oo 
prolapse of rectum, 599 
sterility, 601 
vesical tenesmus, 601 
treatment of, 623 
electric, 623, 626 
Apostoli's 626 

contra-indications, 628 
acute nephritis, 628 
colossal tumors, 628 
fibrocystic tumors, 628 
hysteria, 628 
intestinal catarrh, 628 
malignant degeneration of the 

tumor, 628 
pedunculated submucous fi- 
broid, 628 
pregnancy, 628 
pus in the adnexa, 628 
difficulties of, 627 
electro-puncture, 627 
electrodes, 627 
interpolar methods, 629 
medical, 624 
summary, 656 
surgical, 629 

course, abdominal, accidents, 658 
hemorrhage, 658 
injuries of the hollow viscera, 
658 
of the intestines, 660 
of the ureter, 659 
castration, 641 

contra-indications of, 642 
difficulties of, 642 
vasomotor symptoms re- 
sulting from, 642 
enucleation, 644 
Abdominal Enucleation of 
Myomata and Method of 
Closing the Uterine 
Wound, 643 
hj'sterectomy complete or pan-, 

650 
Koeberle's operation, 645 
partial or supra-vaginal am- 
putation of the uterus, 645 
ligation of vessels, 642 
myomectomy, 643 
Abdominal Myomectomy, 
643 
vaginal procedures, 630 
curetment of uterus, 630 
incision of the capsule, 632 
Cervix and Capsule In- 
cised, the Latter Pushed 
Back, 632 



842 



INDEX. 



Myomata, treatment of, surgical, course, 
vaginal procedures, removal 
of the growth, 633 
Interstitial Tumor Ex- 
posed by Vertical In- 
cision of the Anterior 
Lip, 635 
Myoma of the Anterior 
Wall Exposed by Trans- 
verse and Vertical 
Incision, 536 
by enucleation, 635 
Enucleation of Tumor 
through the Vagina, 

634 
Myoma of Posterior Wall 
Exposed by Retro- 
uterine Incision, 637 

by hysterectomy, 640 
by incision of the pedicle, 6^^ 
Incision of the Pedicle 
of Myoma, 634 
by morcelknent, 637 
Removal of Myoma by 
Morcellment, 638 
by torsion, 633 
Removal of Myoma by 
Torsion of its Pedicle, 
633 
varieties of, 685 
cervical, 695 
extramural, eccentric, or subperitoneal, 

643 
Submucous Fibromyoma Un- 
dergoing Cystic Change, 612 

encapsulated, 586 

nonencapsulated, 586 

penduculated, 586 

sessile, 586, 632 
mural, interstitial, or centric growths, 
586, 590, 632, 636 

circumscribed, general, 592 

diffuse or gigantic, 590 

local, 592 
Myosarcoma, 750 
Myxosarcoma, 750 

N 
Nabothian cysts, 24, 61, 80, 86, 339, 341, 343, 

345, 458, 666, 694 
Nausea and vomiting, 65 
Needles, Curved, 178 

Deschamp's Needle Ligature Carrier, 
410 

Needle Forceps, 178 

Reverdin, 180 

Straight, 178 
Needle with Loop for Suture, 225 
Needle Holder, Doyen, 225 
Neoplasms, 199, 558 

characteristics of benign, 558 

malignant, 582 
Nephrectomy for ureteral fistulas, 256, 260, 

660 
Nephritis, 99 
Nerves, coccygeal, 48 



Nerves, hypogastric plexuses, 48 

inferior hemorrhoidal, 48 

internal pudic, 48 

of the pelvic organs and structures, 48 
Nerves of the Unimpregnated Uterus 
with the Nerves of the Clitoris, 47 

pudic, 48 

spinal and sympathetic, 48 

splanchnic, 48 

trificial, 66 
Neuralgia, 65 

intercostal, 66 

lumbar, 66 

lumbo-abdominal, 66 
Neurasthenia, 66, 363 
Neuroma of vulva, 565 
Notes, value of, 65 
Nubility, 49 

Nuck, canal of, 3, 11, 309, 559 
Nurse, duties of, 759 
Nutrition, disorders of, 66 

organs of, 190 
Nypmhae, absence of, 215 

defects of, 215 

hypertrophy of, 215 

o 

Ointment, belladonna, 197 
benzoated zinc, 307 
betanapothol in vaselin, 311 
camphor, 311 
chloroform, 312 
diachylon, 307 
guaiacol in vaselin, 312, 328 
ichthyol, 307 

in lanolin, 230 
iodoform, 308 
lead acetate, 311 
menthol, 312 

mercury, ammoniated, 307 
opium, 397 
sulphur, 311 
zinc oxide, 308 
Oophorectomy, 641 
05phoritis, 199, 378, 381 
diagnosis, 382 

from gonorrheal infection, 378 

from septic infection, 378 
peri-oophoritis, 380 

Peri-oophoritis. Tube and Ovary 
Encisted, 380 
serosa, 380 

surgical measures, 383 
symptoms, 381 
treatment, 382 
Operation, arrangement for, 170 

Arrangement of Tables and Assistants 
in Operating Room, 171 
assistants, 170 
closure of wounds, 178 
clothing of patient, 170 
examination and preparation of patient for, 

162 
incision, 170 

crescent, 172 
poistion of operator and assistants, 170 



INDEX. 



843 



Operation, precautions during, 160 
preliminar)^ details, 169 ■ 
preparation, special, 162 
room and environment, 161 
Operations, abdominal section, 165 

Alexander Operation ; Round Lig- 
ament Exposed, 472 
Round Ligament Being Drawn 

Out, 473 
Round Ligament Sutured, 474 
Continuous Catgut Suture 
Uniting Internal Oblique 
Muscle to Poupart's Liga- 
ment, 475 
Return Layer of Suture Bring- 
ing External Oblique Muscle 
in Apposition, 476 
modifications of, by Cassati, 476 
by Doleris, 476 
by Duret, 476 
by Edebohls, 475 
by Goldspohn, 476 
by Martin, Franklin, 476 
accidents and results of, 260 

calculi and calcareous concretions, 261 
inclusion of the ureter, 261 
peritonitis, 261 
primary hemorrhage, 260 
secondary hemorrhage, 260 
bladder, for carcinoma of, 579 
extirpation of, for cancer, 579 
tumors, removal of, through the urethra, 

574 ^ 
abdominal incision for, 575 

Fritsch's method, 575 
vaginal incision for, 575 
cervix, amputation of, 233, 346 
Baker's, 700 
amputation of flap, double, 233 
Double Flap Amputation of Cervix, 

232 
Sutures Introduced, 232 
Woimd Closed, 233 

single, 233 
Hegar's, 700 
Schroder's, 234, 700 
Schroder's Single Flap Operation, 

234 
Operation Completed, 235 

vaginal, for cancer of uterus, 700 
Van de Warker's, 700 
wdth galvano- cautery loop, 700 
incision for contracted os, 344 
laceration of, trachelorrhaphy, 231, 345 
Edges of Laceration Turned by 
Tenaculiun Hooked into Each 
Lip, 231 
Denudation of Lacerated Cervix, 

232 
Surfaces Denuded Ready for Union, 

232 
Sutures Introduced, 232 
Sutures Tied, 232 
fistula, entero-vaginal, 263 
recto- vaginal, 261 
uretero-vaginal-uretero-cer\ical, 255 



Operations, fistula, vesi co-uterine, 250 
hysterocleisis, 253 
vesico-utero- vaginal, 254 
vesi CO- vaginal, 239 
colpocleisis, 251 
flap-formation, 248 
flap-splitting, or flap-sHding, 243 
Trendelenburg's operation, 247 
for absent vagina, 207 
for neoplasms, removal of growth by 
incision of pedicle, 633 
by morcellement, 637 
by torsion, 633 
ovary and tube, by abdominal incision, 
castration, 641 
by ovariotomy, 806 
pelvic floor, for laceration of, by denudation, 
Bischofl''s, 271, 278 
Cleveland's 292 

Cleveland's Sutiu-e, 295 
Dudley, 295 
Dudley s Operation with In- 
terrupted Sutures, 296 
Dudley's Operation Com- 
pleted, 296 
Emmet's, 286 
Emmet's Operation. S u r- 
face Denuded and Lat- 
eral Sutures in Place, 
292 
Lateral Angles Closed and 
Perineal Suture Intro- 
duced, 292 
Operation Completed, 293 
Operation for Complete 
Laceration, 293 
Noble's modification of, 287 
Freund's, 286 

Denudation for Freimd's 

Operation, 290 
Sutures Inserted in Rectal 
Wall and Lateral Vaginal 
Angles, 291 
Vaginal Angles and Rectal 
Wall Closed. Suture in 
Place for Perineum, 291 
Denudation Completely 
Closed, 291 
Hegar's, 280 

Garrigues's Modification of, 
281, 285 
Heppner's, 285 
Heppner's Figure-of-8 Su- 
ture, 289 
Hildebrandt's, 285 
Hildebrandt's Method of Su- 
turing, 288 
Suture Closed, 289 
immediate operation, 270 
Lauenstein's Sutmre, 284, 287 
Martin's, A., 285, 296 
Martin s Suture to Close the 
Rectal Opening, 289 
Suture Continued, 290 
Outerbridge's, 290 
Outerbridge's Suture, 294 



844 



INDEX. 



Operations, pelvic floor, primary, 268 
secondary, 270 
Simon-Hegar's, 280 
by flap, 271 
Andrews', 278 

Splitting Vaginal Wall 
Preparatory to Suture, 
280 
Introduction of Suture in 

Retracted Flap, 281 
Suture Tied ; the Remaining 
Surface to be Closed by 
Transverse Sutures, 282 
Duke's, 278, 283 
Fritsch's, 278, 282, 283 
Noble, 287 
Ristine, 277 
Outline of Flap to be Turned 
Down to Form Raw Sur- 
face for Union, 278 
Flap Turned Rown. Sphinc- 
ter closed and Sutures In- 
troduced, 279 
Sanger's, 276 
Simpson's, 274 
Outline for Simpson's Opera- 
tion, 275 
Tait's, 276 

Incision for Tait's Operation 
for Incomplete Laceration 
276 
Line of Incision for Tait's 
Operation for Complete 
Lacerations, 277 
Appearance of Surface after 
Formation of Flaps, 277 
for prolapsus, Alexander's, 444 
Baldy's, 446 
Bovee's, 444 

colporrhaphy, anterior, 442 
Ante/ior Colporrhaphy, 440 

Wound Closed, 441 
posterior, 442 
Dudley's, E. C, 447 
First Stage of Dudley's Bilat- 
eral Denudation of the 
Vaginal Wall for Prolapsus, 

445 
Dudley's Operation. Showing 
Denudation upon one Side of 
the Vagina, 446 

Emmet's, 442 
Freund's, 445 
Garrigues-Hegar, 442 
Gilliam-Ferguson, 444 
Hegar's, 442 
Noble's, 447 
Ries, 444 
Watkins, 441 

Watkins' Operation for Cysto- 

cele, 443 
Situation of the Uterus in 

Completion of the Watkin's 

Operation, 443 
Wiggin's, 446 
plastic, 188 



Operations, sacral, 718 

Skin Incision for Sacral Resection, 

719 
Sacrum Resected; Rectum Ex- 
posed, 720 
Kraske's, 718 

modifications of, by Borelius, 722 
by Hegar, 720 
by Heinecke, 722 
by Herzfeld, 720 
by Hochenegg, 718 
by Kocher, 722 
by Levy, 722 
by Rydygier, 722 
by Schede, 720 
by Schlange, 722 
by Wofiler, 721 
by Zuckerkandl, 721 
upon the uterus, for displacements, ante- 
flexion, abdominal, 459 
Reed, 459 
vaginal, Dudley's, 458 

Dudley's Operation for Ante- 
flexion by Incising and Su- 
turing the Posterior Lip, 459 
Completion of Dudley's Opera- 
tion by Tranverse Denuda- 
tion and Suturing of the 
Anterior Lip, 460 
ante version, 451 
Sims', 451 
Operation for Anteversion, 
450 
Inversion of the uterus, abdominal 
incision, Thomas, 502 
Intraperitoneal Dilatation of 
the Uterus, 503 
vaginal incision, Kiistner's, 502 
Hirst's, 503 
retrodisplacements, abdominal, Alex 
ander's, 473 
modified by Cassati, 476 
Doleris, 476 
Duret, 476 
Edebohls, 475 
Goldspohn, 476 
Martin, F., 476 
Newman, 475 
intraperitoneal shortening of 
the round ligaments, 478 
Baldy, 479 
Bissell, 479 
Burrage, 487 
Dudley's (desmopycnosis) 

478, 479 
Ferguson's, 481 

Section Showing Posi- 
tion of the Uterus with 
the Completion of the 
Operation, 480 
Gilliam, 479 
Round Ligament Drawn 
Through Abdominal 
Wall, 480 
Gilliam-Ferguson Opera- 
tion. Round Ligament 



INDEX. 



845 



Seized through Stab 
Wound, 479 

Operations upon the uterus, retrodisplace- 
ments, intraperitoneal 
shortening of the round 
Hgaments,Montgomery's 
modification, 482 

First Step in My Modi- 
fication of the Gillliam 
Operation for Securing 
Round Ligament Sup- 
port, 481 

Second Step. Showing 
Ligament Fixed with 
Hemostat while Tem- 
porary Ligature is car- 
ried beneath Anterior 
Leaflet of Broad Liga- 
ment with a Des- 
champ's Needle, 482 

Operation Completed, 

483 

Mann's, 477, 478 
Ries, 479 
Schmidt, 487 
Simpson, 481 
^A'ebster, 478 
Wylie's, 477, 478 
ventrofixation and ventrosus- 
pension, 484 
Sutures Introduced for 
Ventrosuspension, 
484 
Bdvee, 485 
Martin, F., 485 
Olshausen's, 484 

Kelly's modification, 484 
vaginal, Bovee's, 488 
Diihressen's, 487 
Freund's, 488 
Gottschalk's, 488 
Mackenrodt's, 487 
Pryor's, 488 
Ries's, 488 
Schiicking's, 487 
Vineberg's, 487 
Wertheim's, 48 7 
for neoplasms, abdominal, 641 
castration, 641 
enucleation, 644 
hysterectomy, Freund, 712 

modified by Bardenheuer, 713 
by Bishop, 655 
by Clark, 714 
by Crede, 713 
by Eastman, 713 
by Gubarofif, 714 
by Kelly, 714 
by Kuhn, 713 
by Mackenrodt, 716 
by A. Martin, 713 
by Polk, 715 
by Ries, 714 
by Rumpf, 714 
by Schroder, 715 
by Veit, 714 



Operations for hysterectomy, modified by 
Werder, 714 
Hgation of the vessels, 642 
myomectomy, 643 
panhysterectomy, 650 
method of Bishop, 655 
of Bouilly, 655 
of Doyen, 652 
The tumor rolled out, in- 
cision made from Douglas' 
pouch into the vagina 
upon the end of a pair of 
forceps, 652 
of A. Martin, 650 
of C. Martin, 651 
of Richelot, 654 
of Schauta, 653 
supravaginal or partial hysterectomy, 

645 

Koberle's 645 

Schroder's 645 
modified by Baer, 646 
by Bishop, 649 
by Gow, 646 
by LeBec, 647 
by Marcy, H. O., 646 
by Pryor-Kelly, 648 
by Zweifel, 646 
vaginal hysterectomy, 640 
Peans', 640 
modified by Billroth, 706 
upon the uterus for abdominal neoplasms, 
vaginal hysterectomy, modi 
fied by Bottini, 706 

by Bovee, 708 

by Byrne, 709 

b}^ Calderini, 706 

by Clark, 708 

by Corradi, 707 

by Czerny, 704, 707, 722 

by Downes, 710 

by Doyen, 706 

by Diihrssen, 708 

by Eastman, 710 

by Franck, 709 

by Fritsch, 706 

by Frommel, 709 

by Kaltenbach, 707 

by Kelly, 707 

by Landau, 706 

by Langenbeck, 704, 709 

by Leopold, 706 

by Liebmann, 707 

by Mackenrodt, 706, 708, 709 

by Mikulicz, 706 

by Miiller, P., 707 

by Newman, 710 

by Olshausen, 706 

by PawHk, 708 

by Pean, 709 

by Richelot, 709 

by Sauter-Recamier, 704 

by Schatz, 706 

by Schauta, 706, 722 

by Schroder, 700, 706 

by Schuchardt, 708 



846 



INDEX. 



Operations upon the uterus for abdominal 
neoplasms, vaginal hysterec- 
tomy, modified by Steinthal, 
727 
by Tauffer, 706 
by von Teuffel, 707 
by TufiEer, 710 
by Veit, 707 
by Wecchi, 706 
by Wertheim, 722 
by Winckel, 707 
by Winter, 709 
by Zweifel, 722 
curetment, 630 
incision of capsule, 632 
of cervix, 63 1 
ligation of vessels, 639 
Gottschalk, 639 
F. Martin, 639 
removal of growth, 6;^^ 
enucleation, 635 
Thomas', 635 
Enucleation of Tumor 
through the Vagina, 634 
incision of Pedicle, 633 

Incision of Pedicle of Myoma, 634 
Morcellement, 637 
Removal of Myoma by Morcell- 
ment, 638 
torsion, 67,^ 
Removal of Myoma by Torsion 
of its Pedicle, 633 
Vulvar, Bartholinitis, 310 
epispadias, 221 
excision of elephantiasis, 564 
of urethral caruncle, 563 
of vulvar vegetations, 565 
extirpation of mahgnant disease of, 520 
Operator and assistants, 160 
Organ of Rosenmiiller, 26, 31 
Organs, interrogation of other, 65 
Os, external, 21 
internal, 21 
tincae, 21 
Ovarian tubes of Pfl tiger, 29 
Ovarian, apoplexy, 507 
hematoma, 617 
tumor, benign, compHcated by malignant 

disease of uterus, 766 
tumors, 766 
adhesions, 802 
characteristics of, 766 
classification of, 766 
dermoid, 780 
Dermoid Ovarian Cyst, 782 
Large Corpus Luteum in Asso- 
ciation with an Ovarian Der- 
moid, 30 
contents of, 780 
large, 768 
Large Ovarian Tumor, 767 
Large Ovarian Cyst, Patient 

Upright, 771 
Ovarian Cyst, Patient Recum- 
bent, 772 
proliferous, 778 



Ovarian tumors, classification of, structure 
of, 776 
areolar, 776 

Areolar Ovarian Cyst, 776 
multilocular, 776, 778 
cyst contents of, 778 
color of, 778 
consistence of, 778 
specific gravity of, 778 
glandular proliferous, 768, 771 
pedicle of, 772 

Pedicle of an Ovarian Cyst, 772 
intrahgamentary, 773, 786 
Intraligamentary Ovarian Cyst, 

773 

Position of Ovary which 
Favors Pendunculation, 
Absence and Intraligament- 
ary Growth, 774 

Cyst Embedded in the Pelvis, 

775 
papillary proliferous, 778 
Small Papillary Ovarian Cyst, 

779 
Papillary Tufs upon Inner 

Wall of Cyst, 779 
Surfaces of Ovaries Infected 
with Papillary Vegetations, 
780 
Papillary Ovarian Cyst, 781 
parovarian, 781 
dermoid, 782 

how distinguished from ovarian, 
782 

prohf crating, 782 
specific gravity, 782 
weight of, 782 
unilocular, 776, 777 
small, 768 
Cysts of the corpus luteimi, 769 
770 
residual, 768 

Small Residual Cyst, 768 
hydatid of Morgagni, 769 
simple or follicular (hydrops 
folliculorum), 769 
etiology, 770 
tubo-ovarian, 770 

Tubo-ovarian Cysts, 770 
adhesions of, 770 
complicanions of, 786 
ascites, 786 

inflammation and suppuration, 786, 
789 
symptoms of, 789 
pregnancy, 791 
An Ovarian Cyst beneath a Preg- 
nant Uterus, 792 
rupture, 790 

torsion of pedicle, 786, 802 
Torsion of Pedicle, 788 
degenerative changes in the walls, 793 
atheromatous, 793 
calcification, 793 
fatty degeneration, 793 
infarctions, 793 



INDEX. 



847 



Ovarian tumors, diagnosis, 793 

Hegar's Method of Determining 
Relation of Tumor to the Uterus, 

799 

differential: 

Relative Zones of Dullness and 
Resonance in Ovarian Cyst, 

797. 

from ascites, 796, 804 
Relative Zones of Dullness 
and Resonance in Ascites, 
796 

from desmoid tumor of abdominal 
wall, 794 
Desmoid Tumor of Abdominal 
Wall, 794 

from distended bladder, 795 

from extrauterine gestation, 801 

from fecal accumulation, 795 

from hematometra, 802 

from hydramnios, 800 

from hydrometra, 802 

from large abdominal tumors, 798 

from localized peritoneal effusion, 

795 
from obesity, 793 

from other abnormal collections, 802 
from physometra, 802 
from pregnancy, 800 
from retroperitoneal growths, 802 
from tympanites, 795 
from uterine myomata, 801 
from ventral hernia, 794 
questions to be considered in, 793 
questions to be considered in explora- 
tory incision, 805 
puncture, 804 

danger and disadvantage of, 805 
etiology, 784 
natural progress, 785 
solid, 782 

carcinoma, 784 
endothelioma, 784 
fibromyoma, 782 
weight of, 783 

Fibromyoma of Ovary, 783 
gyroma, 783 
sarcoma, 784 
Sarcoma of the Ovary, 783 
symptoms, 786 
teratoma, 781 
treatment, 805 
ovariotomy, 806 

causes of death after, 818, 822 
hemorrhage, 822 
ileus, 819, 822 
peritonitis, 822 
shock, 822 
contra-indications for, 807 
general considerations, 807, 816 
instruments, 808 

Cyst Forceps, 808 
management of adhesions, 812 
management of hemorrhage, 

818 
management of pedicle, 813 



Ligatures Introduced 
through Broad Pedicle 
812 
Interlacing of Sutures 
to Prevent Splitting of 
Pedicle, 812 
Sutures Interlaced and 

Tied, 813 
Splitting of Pedicle 
when Sutures are Tied 
Without Interlacing, 
816 
Ovarian tumors, treatment, general consider- 
ations, operation, 809 
postorperative treatment, 817 
puncture and evacuation of 
cyst, 810 
Cyst Punctured and Be- 
ing Withdrawn, 810 
Withdrawal of Sac, 
Showing Adhesions, 
811 
toilet of peritoneum, 809 
incomplete operation, 817 
indications for, 806 
intestinal complications, 821 
mortality, 822 
prognosis, 821 
rupture of cyst, 818 
varieties, 803 
"sdsceral injuries, 819 
Ovaries, absent or rudimentary, 206 
accessory or constricted, 207 
anatomy of, 26 
axis of, 26 
color of, 27 

connection with infundibulopelvic Hga- 
ment, 26 
with uterus, 26 
displacement of, 207 
extra, 207 
Graafian follicles of, 29 

Section of Ovary, Showing Graafian 
Follicles, 28 
situation of, 26 
size of, 27 
stroma of, 29 
tubes of Pfluger, 29 
Ovariotomy, 806. See ovarian tumors. 
Ovaritis, 301, 378 
Ovary, carcinoma of, 784 
inflammation of, 378 
acute, 378 
chronic, 379 
diagnosis of, 382 
gonorrheal, 378 
septic 378 
symptoms, 381 
treatment, 382 
ligament of, 26 
prolapse of, 506 
sarcoma of, 784 
Ovula nabothi, 24 
Ovulation and menstruation, 50 

without menstruation, 50 
Oxyuris vermicularis, 130 



848 



INDEX. 



Pain, 65, 69, 100, 342 
seats of, 70 
accessory, 70 

anal or perineal, 70 
pelvic, 70 
vaginal, 70 
principal, 70 
hypogastric, 70 
iliac, 70 
lumbar, 70 
sympathetic, 66 
Palpation, 77 
Recto-agino-abdominal Palpation, 84 
Rectovesical Palpation, 85 
Panhysterectomy, 650 
Papilloma ta of tube, 762 

Papilloma of the Fallopian Tube, 
762 
of vagina, 581 
of vulva, 565 
Paracentesis abdominis, 103 
Paralysis, motor and sensory, 66 

of intestine, 186 
Parametritis, 386. See Cellulitis. 
Parametritis chronica atrophicans circum- 
scriptum et diffusum, 387 
Parametrium, 39 
Parasites of the genital tract, 116 
animal, 130 
vegetable, 117 
Parauterine pouch, 37 
Parotiditis, 185 
Parovian phleboliths, 765 

tumors, diagnosis of, 781 
Parovarium, 31 

description of, 31 
Pars intermedia, 10 
Parturition, 5, 117, 223 
Patient, comfort of, 49, 182 

examination and preparation of, 162 
Pediculi, 29, 310 
Pediculosis pubis, 130 
Pelvic connective tissue, 39 

Superior View of the Pelvic Cavity, 

34 

diaphragm, 12 
action of, 13 
floor, lacerations of, 264 
causes of, 265 
complete, 265 
degree of extent of, 266 
incomplete, 275 
results of, 267 
treatment of, 269 
inflammations, 365 
organs, study of, as a whole, 48 
displacements, 417 
Pelvis, plane of, 48 
Peptonized milk, 183 
Percussion, 78 

Perimetritis, 394. See Pelvic Peritonitis. 
Perineal muscles, 8 
fascia, 10 
operation for removal of uterus, 724 



Perineum, laceration of, 264 
causes of, 263 
degree of extent, 266 
results of, 267 

Rupture of Perineiun into Recto- 
vaginal Septum, 265 
Incomplete Rupture of the Peri- 
toneum, 266 
treatment of, 269 

intermediate operation, 268, 270 
primary operation, 268 

advantages of, 270, 274 
contraindications, 270 
secondary operation. See Laceration 
of the Pelvic Floor, 
muscles 'of, 8 
nerves of, 17 
Perioophoritis. See Pelvic Peritonitis. 
Perisalpingitis, 293. See Pelvic Peritonitis. 
Peritoneum, Incised, 172 
pelvic, 36 

Covering of the Anterior Uterine 

Wall by Peritoneum, 36 
Posterior Surface of Uterus Show- 
ing Extent of Peritoneum, 37 
Vertical Transverse Section of the 
Pelvis, Showing Peritoneal 
Pouches, 38 
depression of, 38 
reflections of, 37 
toilet of, 174 
Peritonitis, 121, 184, 254, 362 
pelvic, 378, 385, 387, 393 
causes, 395 
diagnosis, 400 
etiology, 394 
pathologic anatomy, 397 
hematosalpinx, 399 
hydrosalpinx, 399 
prognosis, 401 
physical signs, 376 
symptoms, 399 
treatment, 184, 402 
medical, 402 
preventive, 402 
surgical, 402 

incision, abdominal, 405 
closure of wound, 408 

sutures in, 408 
difiiculty in adhesions, 405 
drainage, 407 

intestinal injections of cathar- 
tics, 407 
irrigation, 407 

protection of general perito- 
neum, 407 
incision, vaginal, 355, 408 

Incision through Vagina 
with Thermocautery in 
Vaginal Excision of the 
Uterus, 408 
section, vaginal, and uterine castra 
tion, 410 
tubercular, 124 
Peri-uterine hemorrhage, 514 
Periuterine inflammation, 193 



INDEX. 



849 



Periuterine phlegmon, 386 
Pessaries, 146 

use of, 147 
Pestiary, 146, 438 

bulb, 146 

Chamber's, 148 

cup, 148, 149 

disc, 146, 147 

Gabriel, 502 

Gehrung, 148 

Hewitt, 148, 453 

Hodge, 470 

Menge, 147, 149 

Munde, 147, 470 

ring, 146, 147, 365 

Schultze, 147, 149, 470 
figure-of-eight, 471 
sledge, 149, 471 

soft rubber, 147, 473 

Smith-Hodge, 147 

stem, 148 

Thomas, 147, 148. 456, 470 

WyUe, 148 

Zwank, 147 
Phlebitis, 186, 347, 350 
Phlegmon of the labia, 310 
Physiology of the genital organs, 49 
Physometra, 662 
Pin-worms, 310 
Pipet, Long Glass, 145 
Plicae palmatae, 24 
Pneumococcus, 128, 134 
Polypi, mucous, 193 

of the bladder, 320 

of the uterus, 693 
Polypus, fibroid, 497 

mucous, 663 
treatment, 663 

placental, 664 
Positions for examination, 72 

dorsal, 72, 73 

erect, 74 

genupectoral, 73, 74 

lateral, 73 

lithotomy, 73 

semi-prone, or Sims', 73, 74 

Trendelenberg, 74, 75 
Post-operative treatment, 180 
Pouch of Douglas, 37 

para-uterine, 37 

pubo-vesical, 38 

utero-rectal, 37 

vesico-abdominal, 38 

vesico-uterine, 38 
Poupart's ligament, 39, 355, 474 
Pregnancy, 30, 50, 66, 79, 310 

abdominal, 523 

extra-uterine, 520 
causes of, 520 
course and progress, 523 
mummification, 533 
symptoms, 536 
varieties of, 521 

in bicornate uterus, 533 

ovarian, 521, 533 

tubal. See Ectopic Gestation, 521 

54 



Pregnancy, tubo-ovarian, 522 
tubo-uterine, or interstitial, 522 
with retroflexed uterus, 542 
Probe, Sims', 86 
uterine, 86 
whalebone, 86 
Procidentia, 424, 436 
Prolapse of ova.ry, 506 

Prolapsus, or descent uteri, 422. See Uterus 
Protection from infectious germs, loss of, 117 
Pruritus vulvae, 303 
idiopathic, 310 
prognosis of, 311 
specific cause of, 3 10 
symptoms of, 310 
treatment, 311 
guaiacol in, 311 
Puberty, 49, 93 

changes associated with, 50 
definition, 49 
precocious, 50 
retarded or delayed, 50 
time of occurrence, 49 
Pudendal sac, 11 
Pudendum, 2 
Puncture, exploratory, 103 
Purpura, 190 
Pus tubes, 374 

Section from all of Pus-tube, 373 
Single Fold from all of Pus-tube, 

enlarged, 373 
Distended Pus-tubes, 474 
Incomplete Inflammatory Closure of 
the Fallopian Tube, 375 
PyeHtis, 123,^ 254, 322 
Pyelonephritis, 323, 329 
Pyelonephrosis, 123, 252, 322 
Pyemia, 347 
Pyocolpos, 215 
Pyometra, 673 

Pyosalpinx. See Salpingitis. 
Pyraixiidon, 195 



Quassia, 311 

Quinin, 136, 197, 311, 343, 366 



Radium, 154 
Rectal feeding, 183 
Rectocele, 267, 272, 287, 429 

Rectocele, 268 
Rectovaginal fistula, 220, 223 
Rectum, ampulla of, 35 

anal orifice of, 34 

Imperforate Anus. Communication 
between Rectum and Vagina, 220 

anatomy of, ^^ 

crypts of, 35 

mucous membrane of, 35 

urinary organs and, 31 
Reflexes, rectal, 68 

vesical, 68 
Remedies, specific, 136 
Renal circulation, 190 



850 



INDEX. 



Respiration, 189 
Rest and exercise, 137 
Retractor, 224 
Retractors Simon's, 93 

Retroflexion of the uterus, 459. See Uterus. 
Retroposition of the uterus, 448 
Retroversion, 451. See Uterus. 
Rima pudendum, 2, 88 
Rontgenic rays, 151, 736 
Rosenmliller, organs of, 26 
Round ligament, extraperitoneal method of 
shortening, 473 



S 



Sactosalpinx. See Salpingitis. 
Salpingitis, 254, 301, 330 
acute, 370 
chronic, 371 
diagnosis of, 377, 386 

Double Tubo-ovarian Collection, 376 
Extensive pus collection, with general 

adhesions, 371 
hematosalpinx, 372 
hydrops tubae profluens, 373 
hydrosalpinx or sactosalpinx, 377 
peri-, 375 
Convoluted Fallopian Tube from 
Perisalpingitis, 375 
physical signs, 376 
prognosis, 377 
pyosalpinx, 215, 372, 398, 401, 616 

Double Pyosalpinx, Showing Adhe- 
sions to the Rectum, to the Uterus, 
and on the right, to the Appendix, 
378 
sactosalpinx, 372 
salpingostomy, 383 
Resection of the Tube, 384 
Operation Completed, 384 
symptoms, 381 
treatment, 382, sec, 248 
Salts, 

Epsom, 135, 162 
manganese, 137 
natural, 192 
Kissingen, 192 
Nauheim, 192 
Rochelle, 135, 162 
Sapremia, 3 47 » 349 
symptoms of, 347 
Sarcoma, 572, 583, 747 
diagnosis, 754 

differential, from carcinoma of uterine 
body, 758 
from chorioepithelioma, 758 
from chronic metritis, 757 
from fungous endometritis, 757 
from interstitial endometritis, 758 
from subinvolution, 757 
from tuberculosis of endometrium, 758 
duration of, 754 
etiology of, 751 
metastasis in, 754 
of Fallopian tubes, 763 



Sarcoma, of ovary, 784 
of uterus, 747 
pathology of, 747 
predisposing factors, 752 
recurrence, 758 
symptoms, 752 
treatment, 759 
operative, 759 

contraindications, 759 
varieties of, 747 
Scalpels, 174 
Scissors, 97 

curved, 224, 269 
Kuchenmeister's, 97 
Scopolamin-morphin narcosis, 166 
Secretion and fluid, collection of, 128 

from Fallopian tubes and uterine cavity 

71 
from vagina and vulva, 7 1 

Secretion from Gonorrheal Vagi- 
nitis, 119 
Secretion of Simple Vaginitis 
120 
Segregator, 103, 322 
Sepsis, 155, 370 
Septicemia, 347, 396 
symptoms, 347 
treatment, 351 
Sero-therapy, 351, 352 
Serum, antistreptococcic, 351 
Shock, 183 
Signs, physical, 72 
Silk, 224 

ligatures and sutures, 158 
Silkworm-gut, 166, 178, 244 
Sinuses of Morgagni, 35 
Sinusoidal current, 151 

Skene's ducts, 6, 31, 33, 98, 129, 153, 193, 
316, 565, 814 
follicles, 6 
Urethroscope, 98 
Skin, disturbances of, 190 
Slides, 113 
Cabinet with Trays and Card Index for 

the Preservation of Slides, 114 
Coplin's Method of Indexing and Pre- 
serving Slides, 115 

With Slide enclosed, 115 
Smegma bacillus, 127 
Smell, how used, 72 
Solutions. Bohmer's hematoxylin, iii 
Flemming's, 109 
Fowler's, 182 
Hermann's, 109 
KaiserKng's, 114 
Labarraque's, 163 
Monsell's salt in glycerin, 306 
Sound, 85 
dangers of, 87 

perforation of the uterus by, 87 
precautions in use of, 87 
Simpson's, 86 
Introduction of Sound, 87 
Specula, uterine, 88 

varieties of, Edebohls, 92, 93 
Goodell's, 90 



INDEX. 



851 



Specula, varieties of, Higbee's, 89, 90 
Nelson's, go 
Nott's, 89, 90 
rectal, 85 

Sims' self -retaining, 91, 92 
Proper Method of Holding Sims' 

Speculum, 91 
Talley's, 90 
tubular, 88 

Ferguson's, 88 
univalve or duck-bill, 90 
valvular, 88, 89 
Sphincter ani, 8 
externus, 9 
internus, 9 
tubse, 26 
vaginae, 9 
vesicae, 7,7, 
Sponges, 157, 163 

gauze pads for, 157 
Stain, fuchsin-resorcin, 113. 
Gram's, 118 
hematoxylin, 112 
orcein, 113 

picrolithio-carmin, in 
Staining of tissue, no 

fixation for, in 
Staphylococcus albus, 117 

pyrogenes aureus, 118 
Sterility, 69, 197 
diagnosis, 199 
primary, 197 
secondary, 197 ' 
treatment, 200 
Sterilization methods, 155 
boiUng, 155 
fractional, 156 
heat, 155 
steam, 156 
Steam-pressure Sterilizer, 157 
of dressings, 160 
of instruments, 156 

Sterilizer for Boiling Instruments, 

157 

of ligatures and suttures, 156, 158 
of sponges, 157 
Sterilizer, Arnold's, 156 

Stomach-tube, 184 
Streptococcus pyogenes, 116, 134, 383 
Subinvolution of the uterus, 361, 449 
Subperitoneal growths of the uterus, 594 
Suture, hgature and, material, 158, 178 

catgut, continuous, 179 
Sutures, catgut, 180, 281, 283, 290, 475, 
485. 

chromic, 180, 284 

continuous, 180 

figure-of-eight, 292 

horse-hair, 160 

Lembert, 407, 647 

perineal, 273, 281 

purse-string, 417 

quill of bar, 280 

rectal, 285 

removal of, 187 

silk, 158, 160, 242, 475 



Sutures, silkworm-gut, 160, 180, 242, 282, 
, 409, 473. 485, 652 
silver wire, 160, 242, 290, 292 
Stolz's purse-string, 491 
vaginal, 285 
Symptoms, general, 66 
anemia, 67 
chlorosis, 67 

disorders of nutrition, 66 
gastric, 66 

pains, s}anpathetic, 66 
paralysis, motor and sensory, 66 
visceral, 66 
genital, 69 
local, 67 
objective, 69 
subjective, 65 
Syncytio malignum, 741 
SyphiUs and chancroid, 125, 664 

organisms of, 125 
Syringe, hypodermic, 103 

precautions in use of, 186 
uterine, 175 



Table, Chadwick, 75 

suitable, 75 
Taenia echinococcus, 130 
Tampons, 145, 146 

absorbent cotton, 230 

borated, 146, 230 

boroglycerid in glycerin, 146, 230, 360 

367 

carbohc acid, 146, 230 

carboUzed, 230 

cotton and gauze, 146, 230 

gauze, 145, 177, 230 

glycerin, 146, 230 

ichthyol in glycerin, 146, 230, 360, 366 
in lanolin, 360 

iodoform gauze, 146, 230, 361 

lamb's wool, 145 

sublimated, 146, 230 

sulphuric acid and boroglycerid, 312 

thymoHzed, 230 
Tapping, or paracentesis abdominis, 103 
Tenaculum, 92 

Blunt Hook, 225 

Goodell's, 92 
Tents for dilation, 92 

Dilated Tent Showing Constriction 
from Internal Os, 95 

laminaria, 93 
Hollow Laminaira Tent, 94 

preparation of, 93, 165 

sterilization of, 93, 165 

tupelo, 93, 165 

use of, 165 
Teratoma, 781 
Therapeutics, 134 

classification, 134 

extension of, 134 
Thrombus, vulvar, 513 

vulvo-vaginal, 514 
Torsion of the uterus, 448 
Touch, bimanual, 80 



852 



INDEX. 



Proper Position of the Fingers for 

Examination, 80 
Bimanual Examination, 82 

Touch, employment, of, 72 
information afforded by, 79 
simple, 78 
vaginal, 83 
rectal, 83 
Trachelorrhaphy, 231, 264 
Transversus perinei muscle, 8 
Traumatisms, causes productive of, 223 
general consideration of, 223 
injuries of the genital organs, 223 
treatment of, 224 
Trays, instrument, 157 
Treatment following operations for malignant 

disease, 759 
Trigone, ^3 
Trional, 311 
Triticum repens, 327 
Trocars, 103 

Nest of Trocars, 103 
Tuberculosis of the genital tract, 123 
primary vaginal, 124 
tubal, 193 
Tubes, Fallopian, absent or rudimentary, 
206 
irrigating, 163 
malformations of, 202 
Tubo-ovarian collection, 376 
Tumors, benign, 557 

bladder, 571. See Bladder, 
myoma, 489 
polypi, mucous, 320 
broad Ugament, carcinoma, 766 
echinococcus, 764 
fibroma, 766 
lipomata, 765 

parovarian varicocele, phlebohths, 765 
sarcoma, 766 
cervix, fibromyoma, 595 

Pedunculated Myoma of the 

Cervix, 596 
Sessile Myoma of the Cervix, 
597 
etiology, 597 
symptoms, 598 
pain, 600 
sterility, 601 
Fallopian tubes, 761 
carcinoma, 763 

chorioepithelioma malignum, 764 
dermoid, 761 
enchondromata, 761 
fibrocyst, 761 
hematosalpinx, 762 
hydatid of morgagni, 762 
hydrosalpinx, 762 
lymphangiectasis, 761 
lymphangiectasis cysts, 761 
papillomata, 762 
pyosalpinx, 762 
sarcoma, 763 
serous, 761 
genital, 556 

classification of, 556 



Tumors, hydrocele, 559 
treatment, 560 
malignant, 557, 664, 763 
ovarian, 558, 766 

characteristics of, 766 

cyslic areolar, 776 

cysts of the corpus luteum, 769 

dermoid, 782 

glandular proliferating cystoma, 768, 771 

hydatid of Morgagni, 769 

intraligamentary of ovary and uterus, 

773, 786 
mulitilocular, 776 
papillary cystadenoma, 778 

proliferous, 778 
parovarian, 781 
simple or follicular, 769 
solid, 767, 782 
carcinoma, 784 
endothelioma, 784 
fibromyoma, 782 
gyroma, 783 
residual, 768, 770 
sarcoma, 784 
teratoma, 781 
tubo-ovarian, 776 
unilocular, 776 
urethral, 561 
caruncle, 561 
diagnosis, 562 
etiology, 562 
symptoms, 562 
treatment, 563 
uterine, 585 
Microscopic Section, Myoma, 586 
Submucous Myoma, 588 
Sessile Submucous Myoma, 589 
Submucous Myoma Occupying Uter- 
ine Cavity, 589 
Submucous Myoma Extruded into 

the Vagina, 590 
Circumscribed Interstitial Myomata, 

590 
Local Interstitial Myomata, 591 
Voluminous Mayomata Occupy- 
ing Anterior and Posterior 
Walls, 591 
Uterus Opened Showing Multiple 

Interstitial Myomata, 592 
Sectional Surface of Uterus 
Showing Several Fibroid Tu- 
mors, 593 
Serous Surface of the above, 593 
Uterus Incised, Containing In- 
terstitial Fibromyoma ta, 594 
Uterus Incised Showing General 
Circumscribed Fibromyomata, 

595 
Subserous Myomata, 590 
Bicornate Uterus. Both Cornua 
Containing Myomata, 601 

carcinoma, 313, 665, 743 
etiology, 585, 597 . . 
fibromyomata, 584 

interstitial, mural or centric fibroids 
586, 632, 636 



INDEX. 



8S3 



Tumors, uterine, microscopic appearance, 585 
myocarcinoma, 750 
myochondroma, 750 
myosarcoma, 750 
pathologic anatomy, 585 
puerperal, 662 
hematometra, 662 
hydatid cysts, 662 
hydrometra, 662 
physometra, 662 
symptoms, 599 
varieties, 586 
hard, 586 

interstitial, 586, 590 
soft, 586 
submucous, 587 
sub-peritoneal, 586, 594 
vaginal cysts, 579 

fibroid tumors and polypi, 500 
malignant neoplasms, 582 
papillomata, 581 
vulvar, 564 

cysts, blood, 564 
elephantiasis, 564 
enchondroma, 568 
epithelioma, 568 
fibroma, 567 
lipoma, 568 
myxoma, 567 

papillomata or condylomata, 565 
sarcoma, 568 
Tunica albuginea, 29 
fibrosa, 29 
propria, 29 
Tympanites, 183 
Typhoid bacillus, 127, 349 

U 

Urachus, 221 

Ureter, catheterization of, loi 

description of, 33 

exploration of, 98 

injury of, 650 

irregular exit of, 221 

ligament of, ;^^ 

transplantation of, into bladder, 659 
into rectum, 659 
Ureteritis, 99, 254, 329 

acute, 330 

causes of, 330 

chronic, 330 

symptoms and signs of, 330 

treatment, 331 
Urethra, 14, 31, 49, 221 

absent, 221 

anatomy of , 3 1 

attachment of, 31 

cysts of, 31 

diameter of, 31 

dilatation of, 98 

dimensions of, 31 

exploration of, 98 
Urethra Laid Open with Probes, Dis- 
tending Skene's Glands, Posterior 
Wall Divided, 316 

external meatus, 31 



Urethra, follicular inflammation, 315, 319 
granular erosion, 317, 319 

treatment of, 318 
hyperemia of, 314 
inflammation of, 98 
length of, 31 
mucous membrane, 31 
ulceration of, 316 
symptoms, 316 
Urethral caruncle, 561 
endoscope, 98 
Prolapsus Urethrge, 562 
specula, 98 
Urethritis, 300 

acute catarrhal, 315 
diagnosis, 315, 317 
symptoms, 315 
chronic interstitial, 315, 317 

symptoms, 315 
follicular, 315 
symptoms, 316 
treatment, 318 
gonorrheal, 318 
treatment, 319 
varieties, 314 
Urethrocele, 447 
Urethroscope, Skene's, 98 
Urinary organ and rectum, 31 
Urine, examination of, 99 

incontinence of, 99 
Urogenital sinus, i 
Urotropin, 318, 326 
Uterine polypi, 69 
Uterus, 14, 19, 48 

Half Section of the Pelvis with 
Patient Erect, Showing Normal 
Position of the Uterus, 81 
anatomy of, 19 
anteflexion, 454 

Slight Degree of Anteflexion, 453 
Acute Anteflexion, 454 
Section Showing Thinning of Cer- 
vical Walls at Angle of Flexion, 

457 
Anteflexion Associated with Con- 
traction of Uterosacral Liga- 
ments, 458 

diagnosis, 455 
etiolog}', 455 
symptoms, 455 
treatment, 456 
anteversion of, 449 

Anteversion of the Uterus, 449 
diagnosis, 450 
etiolog}^ 449 
symptoms, 450 
treatment^ 450 
Abdominal Belt, 451 
ascent of, 42 1 

Uterus Pushed up by Tumor in 
Douglas' Pouch, 421 
diagnosis, 422 
atresia of, 204 
Atresia of Rudimetary Horn with an 
Accumulation of Menstrual Blood, 
204 



854 



INDEX. 



Uterus, bicornis, 201 

Uterus Bicornis, 201 
arcuatus, 202 
unicoUis, 202 
Uterus Bicornis Unicollis, 202 
bifidus, 202 

Uterus Bifidus, 202 
biforis, 204 
bilobularis, 202 
bipartitus, 204 

Uterus Bipartitus or Duplex, 205 
biseptus, 205 

Uterus Biseptus, 205 
carcinoma of, 664, 689. See Carcinoma, 
descent or prolapse of, 422 
Vagino-uterine Prolapses with Hy- 
pertrophic Elongation of the 
Cervix, 423 
didelphys, 203 

Uterus Didelphys, 203 
dilatation of, 97, 367 
dimensions of, 20 
dislocation of, 448 

Scheme of Dislocated Uteri, 420 
anteposition, 448 
diagnosis, 448 
latero-position, 448 
retroposition, 448 
displacements, 417 

Displaced by Distended Bladder, 

418 
Displaced by Impacted Rectum, 
419 
complications associated with, 488 
classification, 421 
I general treatment, 489 
prognosis, 489 
summary, 490 
division of, 20 
double, 201 
fetal, 205 
fibromyomatous tumors of, 615. See 

Myoma ta, 
fundus, of 19 
infantile, 205 
inflammation of, 346 
acute, 346 

causes of, 341 
chronic, 338 

areolar hyperplasia, 340 
cervical catarrh, 338 
diagnosis, 343 

differential from endometritis, 

343 
from ovules of Naboth, 343 
from papillary erosion, 340 
symptoms, 338 
classification of, 338 
diagnosis of, 343 
micro-organisms, 338 
physical signs of, 342 
prognosis of, 343 
symptoms of, 342, 347 
treatment of, 343 
constitutional, 343 
douches, 344 



Uterus, inflammation of, treatment of, local, 

343 
tampons, 345 
injuries of the body, 226 

treatment of, 226 
inversion, 492. Inversion of the Uterus-, 
Extravaginal, 499 
degrees of, 492 
Partial Inversion of the Uterus, 

Showing Three Degrees, 492 
Intravaginal Inversion ; Three 

Degrees, 492 
Extravaginal Inversion; Three 
Degrees, 493 
diagnosis, 496 
Palpation of an Inversion of the 

Second Degree, 495 
Appearance of an Inversion of 

the Third Degree, 496 
Inversion of the Uterus, 497 
Submucous Fibroma. Partial In- 
version. Partial Division of 
the Uterus, 498 
etiology, 494 
Nonpuerperal Inversion Fibroid 
Tumor Attached to the Fundus 
Uteri, 493 
symptoms, 495 
treatment, 498 
Central Taxis, 500 
Lateral Taxis, 500 
Peripheral Taxis, 501 
Use of an Air Pessary to Reduce 

an Inversion, 501 
Reduction of Inversion with 
White's Apparatus, 502 
lateral flexion, 488 
lateral version, 453 
malignant tumors, 664 
carcinoma, 644 

adenocarcinoma of body, 671 

of cervix, 669" 
anatomic classification of, 665 
chorioepithelioma, 644, 740 
clinical forms, 679 
complications, 690 
dissemination of, 675 
endothelioma, 664, 746 
epithelioma, 668 
etiology, 683 
physical signs, 689 
sarcoma, 665 . 

squamous cell, 665 
symptoms, 685 
metritis, 346. See Metritis. 
mucous membrane of, 21 

Mucous Membrane of Uterine Body 
Showing Follicles, 22 
polypi of, 663 

confounded with fibroid polypi, 663 
treatment of, 664 
normal position of, 20 
pathologic changes and what constitute, 419 

causes of, 420 
physiologic movements of, 417 

influence on distended bladder, 20 



INDEX. 



85s 



Uterus, polypus placental, 664, 740 
position of, 19 
procidentia of, 424 
prolapsus of, 422 

Prolapsus Uteri without Inversion, 

499. 

classification, 424 
pseudo-prolapsus, 424 
Pseudoprolapsus. Cervix with- 
in Vagina, 426 
Pseudoprolapsus. Cervix pro- 
truding from Vulva, 426 
utero- vaginal, 424 
Uterovaginal Prolapse, 422 
Prolapsus without Protrusion 
of Vaginal Walls, 431 
vagino-uterine, 424 
Vagino-uterine Prolapsus, 423 
Vulvar Appearance of Vagino- 
uterine Prolapsus, 425 
complete, 422 
degrees, 422 
diagnosis, 430 

Recognition of Uterus with 
Thumb and Fingers of One 
Hand, 433 
by bimanual palpation, 432 
Determination of the Position of 
the Uterus by Bimanual Pal- 
pation, 432 
by rectal touch, 434 
Determination of the Position of 
the Uterus by Rectal Touch, 
434 
differential, from cyst on anterior wall 
of vagina, 433 
from cystocele, 431 
from elongated cervix, 432 
Hypertrophic Elongation of 
the Cervix; Anterior Vaginal 
Wall Everted while Posterior 
Retains it Normal Position, 
435 
from entrocele, 434 

Entrocele through the Pos- 
terior Vaginal Fornix, 435 
from inversion of the uterus asso- 
ciated with inversion of vagina, 
432 
from rectocele, 431 
etiology, 424 

Irreducible Prolapsus, 430 
prognosis, 434 
symptoms, 428 
cystocele, 429 
rectocele, 429 
Prolapsus with both Rectocele 
and Cystocele, 429 
treatment, 437 
hygienic, 437 
mechanical, 438 
operative, 439. See operations. 
Anterior Colporrhaphy. An- 
terior Vaginal Wall Re- 
moved, 440 
puerperal tumors, 662 



Uterus, puerperal tumors, hematometra, 662 
hydrometra, 662 
physometra, 662 
pyometra, 662 
retroflexion, 459 , 

Retroflexion of Slight Degree, 462 
Retroflexion of Extreme Degree, 
462 
. diagnosis, 464 

Retroflexion Simulated by Poste- 
rior Uterine Myoma, 464 
Retroflexion Simulated by Small 
Ovarian Cyst in Posterior Culde- 
sac, 465 
Anteflexion and Retroflexion Simu- 
lated by Pelvic Exudation, 465 
etiology, 460 
Retroflexion following Version, 

463 
Retroflexion produced by Fibroma 

of Anterior Vaginal Wall, 463 
Retroflexion the Sequel of Inflam- 
matory Adhesions, 464 
extraperitoneal shortening of the round 

ligament, 473 
symptoms, 460 
treatment, 466 
retroversion, 451 

Retroversion, 452 
diagnosis, 453 
etiology, 452 
symptoms, 452 
treatment, 466 

Retroverted Uterus Replaced, 

466 
Proper Position of Pessary, 469 
Faulty Position of the Pessary, 
470 
operative procedures, 473 
rudimentary, 204 
sarcoma, 747. See Sarcoma, 
torsion of, 448 

Traction upon Uterus with Double 
Tenaculum during Digital Examina- 
tion by the Rectum, 94 
Virgin Uterus, Median Section, 22 
unequal development of two sides of, 203 
unicornis, 203 

Uterus Unicornis, 203 
weight of, 20 



Vaccine- therapy, 351, 352 
Vagina, 14 

Anterior Wall of Vagina, 1 8 

Horizontal Section of the Vagina 
and Urethra of an Infant, 1 9 
absent, 207 

treatment of, 207, 208 
Line of Incision for Formation of 

Flaps, 208 
Flaps Outlined in above Sutured 
Place and Denuded Surfaces 
which have Furnished Flaps to 
line Posterior Wall, 209 
atresia of, 211, 215 



856 



INDEX. 



Communication of Rectum and Bladder 
with the Vagina, 222 
Suprapubic Opening of Vagina and 
Urethra, 222 

Vagina, atresia of, congenital defects of, 221 
cysts of, 579 

Cysts of the Vagina, 580 

diagnosis, 579 

symptoms, 579 

treatment, 580. 
double, 210 

Double Vagina, 211 
epithelioma of, 582 
fibroid tumors and polypi of, 580 

Myoma of the Anterior Vaginal 
Wall, 581 

diagnosis, 581 

symptoms, 581 

treatment, 581 
lacerations of, 234 
lymphatics of, 19 
malignant neoplasms, 582 

Primary Cancer of the Vagina, 582 

etiology of, 582 

symptoms, 583 

treatment, 583 
mucous membrane of, 18 

secretion of, 18 
nerves, 19 
papilloma ta of, 581 
posterior fornix of, 17 
rudimentary, 207 
rugae of, 16, 18 
sarcoma of, 583 
wall of, 14, 18 
Vaginal, irrigation, 188 

septum, 205 
Vaginismus, 68, 196 
causes of, 196 
prognosis of, 196 
symptoms of, 196 
treatment, 196 
Vaginitis, colpitis, or elytritis, 301, 316, 332 
diagnosis, 335 
etiology, 334 
pathology, 334 

of simple, 335 

of specific, 335 
prognosis, 336 
symptoms, 335 
synonyms, 332 
treatment, 336 
varieties, 333 

diphtheric, 334 

dysenteric, 330 

emphysematous, 128, 333 

exfoliative, 333 

phlegmonous, 333 

senile, 333 

specific, 334 
Valve of Houston, 36 
Varicocele, parovarian, phleboliths, 765 
Vascular supply of pelvic organs, 39 
Veins, internal iliac, 43 
left ovarian, 43 
ovarian, 40, 43 



Veins, pampiniform plexus, 43 
plexus of hemorrhoidal, 42, 44 
right ovarian, 43 
superficial abdominal enlarged by pressure, 

76 
uterine, 40 
vaginal, 43 
varicose, 563 
vesical plexus, 42 
Relation of the Urethral and Vaginal 
Venous Plexuses to the Veins of the 
Clitoris and Bulb, 43 
Veins and Erectile Venous Plexuses 

of the Female Pelvis, 44 
Erectile Organs and Veins of the 
Female Perineum, 45 
Ventrofixation of the uterus, 444 
Ventrosuspension of uterus, 444 

advantages and disadvantages of, 486 
Version, lateral, 453 
Vessels, Distribution of Uterine and 

Ovarian, 40 
Vesical reflexes, 68 
Vesico-uterine fissure, 316 
Vesico-vaginal fistula, 221 
Vestibule, 5 

bulb of, 9 ■ 

Violence, external to genital organs, 223 
Virgins, examination of, 83 
Vitelline membrane, 29 
Volvulus, 186 
Vomiting, 388 

following operation, 182 
in peritonitis, 183 
Vulsellum, Three-pronged, 407 
Vulva, 2 

Virgin Vulva ; Labia not Separated, 4 
Virgin Vulva ; Labia Separated Show- 
ing the Hymen Unruptured, 5 
absence of, 215 
defects of, 215 
edema of, 303, 564 
eruptive diseases of, 304 
catarrhal, 306 
causes of, 305 
diagnosis, 305 
diphtheric, 307 
eczema of, 304 
erysipelas of, 304 
herpes of, 304 
phlegmonous, 305 
treatment, 306 
gangrene of, 308 
kraursis, 312 

Kraurosis Vulvae, 313 
neuroma, 565 

treatment of, 565 
pruritus, 310 
tumors, 564 

benign, classification of, 564 
cysts, 564 
blood, 564 
hydrocele, 559 

differential diagnosis from hernia, 

500 
treatment, 560 



INDEX. 



8S7 



Vulva, tumors, cysts, of glands of Bartholin, 

564 

of hymen, 565 

of urethra, 565 

sebaceous, 564 
elephantiasis, 564 

Elephantiasis of the Vulva, 567 

diagnosis, 564 

forms of, 564 

symptoms of, 564 
enchondroma, 568 

urethral caruncle, 561 
fibroma and myxoma, 567 

Fibroid of Labium, 568 
lipoma, 568 
malignant, 568 

Cancer of the Vulva, 569 

adenocarcinoma, 568 

diagnosis, 569 

epithelioma, 568 

prognosis, 570 

sarcoma, 568 

symptoms, 568 

treatment, 570 
varicose veins of, 563 

Varicose Veins of the Vulva, 563 

Vulvar Vegetations, 566 
Vulvitis, 301, 311, 316 
catarrhal, 302 



Vulvitis, causes of, 302 

chancroidal, 304 

diphtheric, 305, 307 

follicular, 303 
Follicular Vulvitis, 303 

gonorrheal, 304, 306 

simple or catarrhal, 302 

syphilitic, 304 

venereal, 303 
Vulvo-vaginal glands, 9 
Vulvo-vaginitis in young girls, 331 

W 

Widal reactions, 349 
Wolffian Body, i, 761, 781 
Wound, closure of, 178 
dressing, 180 
infection, 180 
materials for suturing, 178 
methods of suturing, 179 
Peritoneum Nearly Closed with Con- 
tinuous Catgut, 179 
Silkworm-gut Sutures Tied, 179 
post-operative treatment, 180 



X 



X-rays, 151 

Zona pellucida, 29 



m 13 1912 



i.n 



one copy del. to Cat. Div. 
IAS 13 191 



